Recovery and processing of human embryos formed in vivo

ABSTRACT

A kit having instructions for use for performing uterine lavage in a female patient includes a uterine lavage catheter configured for insertion into a woman&#39;s uterus to remove viable blastocysts from the uterus, and one or more first containers having a sufficient dosage amount of a GnRH antagonist to cause desynchronization of the endometrium of the patient prior to, during and/or following recovery of viable blastocysts from the uterus.

CROSS-REFERENCE TO RELATED APPLICATION

The present application is a continuation of U.S. patent applicationSer. No. 14/642,437, filed Mar. 9, 2015, which is a continuation-in-partof U.S. patent application Ser. No. 13/924,520, filed Jun. 21, 2013, andwhich is a continuation-in-part of U.S. patent application Ser. No.13/335,170, filed Dec. 22, 2011. The contents of the prior applicationsare incorporated herein by reference in their entirety.

BACKGROUND

Uterine lavage for recovery of human embryos was developed and reportedin human subjects by the applicant three decades ago. A University ofCalifornia Los Angeles team, directed by the applicant, recovered andtransferred in vivo fertilized embryos from fertile to infertilerecipient women. This technique produced donor-to-recipient transplantedhuman pregnancies, reported in 1983 and delivered in 1984.

SUMMARY

In general, in an aspect, at a time when a woman's uterus contains invivo fertilized preimplantation embryos, a seal is provided, between theuterus and the external environment, against flow of fluid from theuterus to the external environment. While the seal is provided, fluid isdelivered past the seal and into the uterus. The delivered fluid iswithdrawn, with the embryos, past the seal and from the uterus to theexternal environment.

Implementations may include one or more of the following features. Therecovered in vivo pre-implantation embryos are recovered for geneticdiagnosis or genetic therapy or sex determination or any combination oftwo or more of them. One or more of the embryos are returned to theuterus of the woman. The one or more embryos are returned to the uterusof the woman without having frozen the embryos. The embryos resultedfrom artificial insemination. The embryos resulted from causingsuperovulation in the woman. The superovulation is caused in the woman.The artificial insemination is caused in the woman. At least one of thepre-implantation embryos is treated. The treating includes gene therapy.The in vivo fertilized preimplantation embryos are withdrawn from theuterus with an efficiency of greater than 50%. The in vivo fertilizedpreimplantation embryos are withdrawn from the uterus with an efficiencyof greater than 80%.

The in vivo fertilized preimplantation embryos are withdrawn from theuterus with an efficiency of greater than 90%. The in vivo fertilizedpreimplantation embryos are withdrawn from the uterus with an efficiencyof greater than 95%. The embryos are frozen. The delivering orwithdrawing or both of the fluid is pulsatile. The fluid is withdrawnwhile the seal is being provided. The seal enables essentially all ofthe fluid to be withdrawn. The withdrawing of fluid includes aspiratingthe fluid from the uterus. Both the delivering and the withdrawing arepulsatile and the pulses of the delivering of the fluid and of thewithdrawing of the fluid are coordinated.

In one embodiment, a kit having instructions for use for performinguterine lavage in a female patient is disclosed which comprises auterine lavage catheter configured for insertion into a woman's uterusto remove blastocysts from the uterus; and at least a first containercomprising a GnRH antagonist. The GnRH antagonist may be provided in asufficient dosage amount to prevent premature ovulation whilestimulating the ovaries with FSH and/or LH, and/or an additional,separate container of GnRH antagonist may be provided comprising asufficient dosage amount of a GnRH antagonist to cause corpus luteumapoptosis leading to desynchronization of the endometrium followingsuperovulation and prior to, during and/or following recovery of viableblastocysts from the uterus.

Another embodiment of a kit for uterine lavage comprises a uterinelavage catheter configured for insertion into a woman's uterus to removeblastocysts from the uterus; one or more first containers comprising asufficient dosage amount of FSH and/or LH appropriate for induction ofsuperovulation in a woman; and one or more second containers comprisinga sufficient dosage amount of a GnRH antagonist to cause corpus luteumapoptosis leading to desynchronization of the endometrium followingsuperovulation. The kit may include instructions for use foradministering the FSH and/or LH by self-injection, in which the dosageamount of FSH and/or LH is appropriate for induction of superovulation,in vivo fertilization, and embryonic maturation. For example, the kitmay include instructions for use for self-injecting the FSH and/or LHusing 5 to 20 daily injections at ranges of 12.5 to 1200 mIU per day.The FSH and/or LH may comprise at least one of at least one ofinjectable menotropins containing both FSH and LH; urofollitropinscontaining purified FSH; recombinant pure FSH; or single doses ofrecombinant long acting pure FSH.

The kit may also comprise one or more additional containers comprising asufficient dosage amount of GnRH antagonists to prevent prematureovulation while stimulating the ovaries with FSH and/or LH. The GnRHantagonists may comprise receptor blocker peptides, such as at least oneof CETROTIDE 0.25 to 3 mg, GANIRELIX, ABARELIX, CETRORELIX, DEGARELIX orELAGOLIX. The kit may further comprise one ore more additionalcontainers comprising a sufficient dosage amount of GnRH agonist toprevent premature ovulation while stimulating the ovaries with FSHand/or LH, and/or including instructions for use for administering asingle or multiple doses of GnRH agonist subcutaneously or nasally totrigger superovulation. The GnRH agonist for superovulation maycomprise, for example, at least one of Leuprorelin, Leuprolide acetate,nafarelin, or naferilin acetate snuff, or Buserelin. The kit may furtherinclude instructions for use for administering a single or multipledoses of urinary or recombinant hCG or LH surrogate nasally, orally,subcutaneously, intramuscularly, transdermally, vaginally, rectally, orbuccally to trigger ovulation. The kit may further include one or moreadditional containers with a sufficient dosage amount of hCG or LHsurrogate to cause superovulation. The hCG or LH surrogate forsuperovulation may be, for example, at least one of PREGNYL, NOVAREL orOVIDREL.

In another embodiment of a kit for uterine lavage, a kit is disclosedwhich comprises a uterine lavage catheter configured for insertion intoa woman's uterus to remove blastocysts from the uterus; one or morefirst containers comprising a sufficient dosage amount of FSH and/or LHappropriate for induction of superovulation; one or more secondcontainers comprising a sufficient dosage amount of a GnRH antagonist toprevent premature ovulation while stimulating the ovaries with FSHand/or LH; and one or more third containers comprising a GnRH antagonistto be administered after superovulation.

In another embodiment of the invention, a kit is disclosed whichcomprises a uterine lavage catheter configured for insertion into awoman's uterus to remove blastocysts from the uterus; one or more firstcontainers for storing one or more of a biopsied trophectoderm cells orinner cell mass recovered from the one or more blastocysts following abiopsy procedure to remove the one or more biopsied cells from therecovered blastocysts; and one or more second containers for storing andcryopreserving the one or more of the recovered blastocysts followingthe biopsy procedure, wherein the one or more first and secondcontainers each comprise one or more labels for identifying the one ormore biopsied cells and the blastocyst from which the one or morebiopsied cells was removed. The kit may further comprise one or morethird containers comprising a sufficient dosage amount of a GnRHantagonist to cause corpus luteum apoptosis leading to desynchronizationof the endometrium of the patient prior to, during and/or followingrecovery of blastocysts from the uterus. Both of the one or more secondand third containers preferably comprises an electronic or other codinglabel including the biopsied cell and blastocyst identificationinformation. The one or more second containers may comprise, forexample, one or more vials for storing and cryopreserving one or more ofthe recovered blastocysts following the biopsy procedure.

The kit may further comprise instructions for use for performing atleast one molecular diagnostic assay test on one or more of therecovered blastocysts following recovery of same from the uterus. Thekit may comprise at least one instrument or agent for performing abiopsy procedure to remove biopsied cells, e.g., trophectoderm cells ortargeted inner cell mass, from the one or more recovered blastocysts.For example, the instrument may comprise a holding tool to stabilize oneor more of the recovered blastocysts during the biopsy procedure. Theinstrument may also comprise a control kit to ensure there is nocontamination in the biopsied cells. The kit may further comprise amicropipette for performing the biopsy and removing the cells from theblastocysts. The kit can include instructions for use for processing andhandling (e.g., cryopreserving) the biopsied cells.

With respect to the molecular genetic testing, the kit may comprise oneor more reagents comprising nucleotide sequences capable of hybridizingwith known chromosonal abnormalities, e.g., that may be found in thebiopsied cells. The kit may further comprise a microarray and/or a genechip which is configured to hybridize with such chromosomalabnormalities, single gene mutations, corresponding normal sequencesand/or sequences neighboring the chromosomal abnormalities. Theinstructions for performing at least one molecular diagnostic assay testmay comprise instructions for molecular testing for a variety of knowngenetic disorders such as Down syndrome, and the kit may compriseinstructions for use for therapeutic embryonic intervention usingselective replacement or gene therapy with specific corrective geneticconstructs, specific non-genetic constructs, or stem cell/embryonic celltransplants following the at least one molecular diagnostic assay test.The kit may also include instructions for use for inserting thetherapeutically treated embryo into the woman's uterus followingembryonic intervention.

The kits noted above and herein may additionally comprise additionalcompound containers including, for example, progesterone and estradiol,respectively. The progesterone may be at least one of vaginalprogesterone or oral progesterone. The estradiol may be at least one oforal or transdermal estradiol, e.g., the estradiol may be transdermalestradiol patches 400 ug per day or oral estradiol 4.0 mg per day.

Other possible components of the kit include a controller forcontrolling the pressure and vacuum applied to the uterine lavagecatheter, catheter introducers, a pump and/or vacuum system and/ortubes, a cell culture vial for containing the blastocysts followingrecovery and which maintains optimal CO2/O2 concentration for blastocystculture without the requirement of an incubator, or other cell-culturedevices. The kit may be in packaged combination, such as in a pouch, bagor the like. The kit may further include instructions for the use ofcomponents of the kit in a uterine lavage procedure, such asinstructions for use of the compounds to induce superovulation, preventpremature ovulation while stimulating the ovaries with FSH and/or LH,and/or cause corpus luteum apoptosis leading to desynchronization of theendometrium of a patient undergoing a uterine lavage procedure.

In another aspect of the invention, a composition suitable foradministration to a human female patient during superovulation isdisclosed. The composition may include a GnRH antagonist in an amountsufficient to prevent premature ovulation while stimulating the ovarieswith FSH and/or LH. The composition may be, for example a GnRHantagonist in a pharmaceutically acceptable solution at a dosage amountof about 0.10 to 400 mg, e.g., about 0.5 to 400 mg, e.g., about 0.25 to10.0 mg. e.g., at a dosage amount of between about 0.5 to 10.0 mg, e.g.,about 0.5 to 5.0 mg, e.g., in certain cases at a dosage amount ofbetween 0.25 and 3.0 mg. The GnRH antagonist may include at least one ofCETROTIDE, GANIRELIX, ABARELIX, CETRORELIX, DEGARELIX or ELAGOLIX.

In another aspect of the invention, a composition suitable foradministration to a human female patient following superovulation andprior to, during and/or following removal of blastocysts from the uterusis disclosed. The composition may comprise a GnRH antagonist in anamount sufficient to cause corpus luteum apoptosis leading todesynchronization of the endometrium to reduce the chance that anyembryos remain in the uterus will form a viable pregnancy followingsuperovulation. The GnRH antagonist is in, for example, apharmaceutically acceptable carrier at a dosage amount of about 0.10 to400 mg, e.g., about 0.5 to 400 mg, e.g., about 0.25 to 10.0 mg, e.g.,about 0.5 to 10.0 mg, and in certain cases between about 0.25 to 3.0 mg.Desynchronization may include administering GnRH antagonist before theday or on the day on which the blastocysts are recovered, and daily forup to ten days or until the onset of menses following blastocystrecovery to induce corpus luteum apoptosis, suppress luteal phaseprogesterone, and further decrease risk of a retained (on account ofblastocysts missed by the intrauterine lavage) pregnancy. The GnRHantagonist may include at least one of CETROTIDE, GANIRELIX, ABARELIX,CETRORELIX, DEGARELIX or ELAGOLIX, e.g., at a dosage of between about0.5 to 10.0 mg, e.g., at a dosage amount of between about 0.5 to 5.0 mg,e.g., at a dosage amount of between 0.5 and 3.0 mg. In one embodiment,CETROTIDE at 3.0 mg is administered to cause said corpus luteumapoptosis leading to said desynchronization. The method may furthercomprise administering a progesterone receptor antagonist to thepatient. The progesterone receptor antagonist may comprise, for example,Mifepristone at a dosage of about 600 mg. The progesterone receptorantagonist may comprise, for example, Onapristone at a dosage of betweenabout 100 to 200 mg. The progesterone receptor antagonist may compriseUlipristal, Org 31710 (e.g., 10 to 75 mg) or other suitable GnRHreceptor blocker antagonists.

Methods are provided for administering an effective amount of thecompositions (e.g., orally, nasally, intramuscularly, subcutaneously,etc.) to a patient to cause corpus luteum apoptosis leading todesynchronization. Use of this method will reduce or eliminate thepossibility that unrecovered blastocysts will implant and result inunintended pregnancy. Previous uterine lavage studies were done onnon-stimulated cycles, as such the risk of retained pregnancy wassignificantly lower.

In another embodiment, a sterile dosage form of GnRH antagonist isprovided, which may be provided in a form suitable for use in a surgicalprocedure. The dosage form of GnRH antagonist may be in apharmaceutically acceptable form for parenteral administration, forexample to the uterus. The GnRH antagonist may be provided in a varietyof pharmaceutically acceptable carriers. In one embodiment, a steriledosage form of GnRH antagonist is provided comprising about 0.25 to 10.0mg, e.g., about 0.5 to 5.0 mg, e.g., 0.25 to 3.0 mg of antagonist in apharmaceutically acceptable carrier. Carriers may include aqueoussolutions including saline, aqueous solutions including dextrose, waterand buffered aqueous solutions, as well as oral formulations of theantagonist.

In another aspect of the invention, a uterine lavage system comprises afluid delivery and collection device; and a controller programmed todeliver lavage liquid to the uterus to assist with the recovery ofblastocysts from the uterus at a flow of fluid supply that substantiallylimits or prevents the flow of fluid into the fallopian tubes whereblastocysts may be lost, e.g., that does not exceed a maximum pressureof the device of between about 2 ounces per square inch and 50 pounds ofpressure per square inch, e.g., between about 2 ounces and 20 pounds ofpressure per square inch. The controller may be programmed to controlthe delivery of the fluid through the fluid delivery and collectiondevice into the uterus in a series of pulses at a pre-determined pulserate. For example, the pulse rate may have a preset frequency in therange of one pulse per 0.5 to 4 seconds, e.g., one pulse per 1 to 3seconds, e.g. one pulse per 2 to 3 seconds, e.g. one pulse per 3seconds.

In another aspect, a uterine lavage system is disclosed which comprisesa fluid delivery and collection device; and a controller programmed todeliver lavage liquid to the uterus from the device to assist with therecovery of blastocysts from the uterus and to apply vacuum pressure tothe fluid to maintain the integrity of the blastocysts during fluiddelivery and removal, e.g., between about 2 to 30 Hg of vacuum, e.g.,between about 10 to 30 Hg of vacuum, e.g., between about 10 to 14 Hg ofvacuum pressure. The uterine cavity is preferably not expanded orpressurized. The lavage device does not include any members that act toexpand the uterine cavity; as such an expansion can introduce air intothe uterine cavity, which can kill blastocysts. The lavage process isdesigned to prevent the introduction of air into the uterine cavity toensure the health and integrity of the recovered blastocysts.

In another aspect, lavage fluid may be collected directly into acell-culture system capable of maintaining blastocyst viability duringshipment to the central embryological laboratory. Such a system wouldmaintain blastocyst-safe O2/CO2 levels without the requirement of anincubator and eliminate the need to dilute lavage fluid with physiologictransport media thus streamlining the recovery and shipment ofpre-implantation embryos captured through uterine lavage.

A method of uterine lavage is disclosed which comprises deliveringlavage fluid to the uterus of a female patient and applying a vacuumpressure to the fluid to recover blastocysts from the uterus, whereinthe flow of fluid is controlled so as not to exceed a maximum pressureof between about 2 ounces per square inch and 50 pounds of pressure persquare inch, e.g., between about 2 ounces and 20 pounds of pressure persquare inch to limit or prevent leakage of fluid into the fallopiantubes.

In another aspect of the invention, a uterine lavage system is disclosedwhich comprises a fluid delivery and collection device; and a controllerprogrammed to both deliver lavage liquid to the uterus and apply vacuumto the fluid delivery and collection device, wherein the controllerincludes control logic which controls the fluid delivery and collectiondevice so as to cause injecting a first small amount of fluid into theuterus to form a first puddle of fluid encompassing one or moreblastocysts and to cause said first puddle of fluid to be suctioned intothe device along with the one or more entrained blastocysts, and toinject at least one second amount of fluid into the uterus to form asecond puddle which is larger than the first puddle and to suction thesecond puddle into the device along with one or more entrainedblastocysts. The lavage cycle is started when the controller is promptedto begin the preset lavage cycle consisting pulsed fluid delivery andcollection cycles. The first stage of the lavage cycle is begun byinjecting a small amount of fluid into the uterine cavity to form apuddle of fluid encompassing the pre-implantation embryos. All of thefluid present in the uterine cavity is then suctioned into the systemwith one or more entrained pre-implantation embryos. The second stage ofthe lavage cycle is begun by injecting a larger amount of fluid into theuterus to form a larger puddle. All of the fluid present in the uterinecavity is then suctioned into the catheter.

The controller may be programmed to control the delivery of the fluidthrough the fluid delivery and collection device into the uterus in aseries of pulses at a pre-determined pulse rate. For example, the pulserate may have a preset frequency in the range of one pulse per 0.5 to 4seconds. The controller may also be programmed to control the withdrawalof the fluid through the fluid delivery and collection device from theuterus in a series of vacuum pulses at a pre-determined pulse rate,e.g., at a vacuum pressure between about 2 to 30 Hg of vacuum, e.g.,between about 10 to 30 Hg of vacuum, e.g., between about 10 to 14 Hg ofvacuum pressure.

These and other aspects, features, and implementations, and others, andcombinations of them, can be expressed as methods, apparatus, systems,components, program products, business methods, means or steps forperforming functions, and in other ways.

These and other aspects, features, and implementations will becomeapparent from the following description and from the claims.

DESCRIPTION

FIGS. 1, 2, 3, 4, 7 b, 9, 10, 11, 35 a through 35 f, 52, through 58, 63a through 63 q, and 64 a through 64 e are sectional views of femalereproductive tracts.

FIG. 5 is a schematic perspective view of a procedure on a blastocyst.

FIG. 6 illustrates a genetic diagnosis

FIGS. 7a, 13c through 13f illustrate a step in a lavage procedure.

FIG. 8a is a flow chart.

FIG. 8b is a time diagram.

FIGS. 12a through 12d illustrate aspects of business models.

FIGS. 13a , 14, 36, and 37 are side views of lavage instruments.

FIG. 13b is a perspective view of a lavage instrument on a stand.

FIGS. 15, 16, 38, and 39 are top views of lavage instruments.

FIG. 17 is a side view of a catheter.

FIGS. 18, 19, 21, 24, 41, 42, 45, and 48 are perspective views ofportions of lavage instruments.

FIG. 20 is an enlarged side sectional view, partially cut away, of acatheter.

FIGS. 22, 25, 46, and 49 are cross-sectional views of catheters.

FIGS. 23 and 47 are side views of portions of lavage instruments.

FIGS. 26, 27, 28, 29, 30, 40, 50, and 51 are side views of catheters.

FIG. 31 is an enlarged sectional view of a tip of a catheter.

FIGS. 32, 33, 34 a, 34 b, 61 a, 61 b, 62 a, and 62 b are perspectiveviews of cannula tips with balloons.

FIGS. 43 and 44 are side views of catheters partly in section.

FIGS. 59a and 59b are side views of tips of catheters.

FIG. 60a is a perspective view of tips of catheters.

FIG. 60b is a side sectional view of tips of catheters.

Here we describe a way to achieve early (e.g., very early) diagnosis andtreatment of genetic disorders in human preimplantation embryos(blastocysts) conceived in vivo and recovered from the reproductivetracts of fertile women. Important beneficiaries of what we describehere are women who, in specific unions with their male partners, arefaced with parenting yet-to-be-born children at (significant) risk forchildhood or adult onset genetic diseases.

As shown in FIG. 1, in examples of the technique that we describe here,such an at-risk woman is induced to superovulate multiple oocytes 124using fertility drugs. Superovulation is followed by artificialintrauterine insemination (FIG. 2a ) by her partner's sperm 128 and invivo fertilization in her reproductive tract to produce preimplantationembryos (blastocysts) (FIG. 3). The blastocysts 88 (blastocysts of 5-8days gestational age) are recovered by uterine lavage (FIGS. 3, 4).Embryonic micromanipulation with biopsy then is used to removetrophectoderm 134 (early placenta) or targeted inner cell mass (earlyfetal cells) from one or more of the recovered blastocysts (FIG. 5). Thebiopsied trophectoderm cells 134 are used, for example, for moleculardiagnosis of specific genetic disorders, for example (FIG. 6) Downsyndrome where there is an extra #21 chromosome, three instead of two.The diagnosis is followed by therapeutic embryonic intervention usingselective replacement or gene therapy with specific corrective geneticconstructs or stem cell/embryonic cell transplants. The diagnosed ortreated embryos 132 are then replaced into the woman's uterine cavity126 leading to a viable unaffected birth nine months later (FIG. 7)

An important feature of this process is uterine lavage, typically anonsurgical office technique that allows recovery of humanpreimplantation embryos naturally conceived in vivo, in a woman's body.

In some examples of the approach that we describe here, uterine lavage,and ancillary devices, steps, and services related to it and builtaround it, provide a simple, safe, and inexpensive way to diagnose andtreat human embryos before implantation (preimplantation geneticdiagnosis, PGD) or to make a sex determination or both.

One known platform for performing PGD is in vitro fertilization (IVF), atreatment for infertility in clinical use for over 30 years.Exploitation of PGD by IVF has been limited since the introduction ofPGD 20 years ago. PGD by uterine lavage is expected to be lessexpensive, less technically difficult, and more cost efficient than PGDusing IVF.

PGD by uterine lavage is technically simpler than IVF because itexploits natural in vivo fertilization in the body of the patient toavoid the laboratory complexities of IVF. The efficiency of lavage (thatis, the cost per recovered viable blastocysts) is not fully known;however, there are reasons to believe the efficiency of in vivofertilization and recovery by uterine lavage will be higher than IVF inpart because it can be repeated until successful. It also should costconsiderably less than with IVF, because the laboratory complexities offertilization in vitro are bypassed and uterine lavage is technically asimpler office procedure. The procedural cost to recover embryos fordiagnosis is expected to be in the range of $2,500 to $5,000 perattempt. It is expected that the number of lavage attempts needed togenerate a viable pregnancy, depending on the woman's age, will rangebetween 1 and 4 lavages.

Certain of the specific steps that we describe here (FIG. 8a ) haveindividually been the subject of previous fragmentary reports:superovulation 152, artificial insemination 154, in vivo fertilization156, embryo recovery by uterine lavage 158, embryo biopsy 160,preimplantation diagnosis 162, preimplantation therapy when feasible164, embryo freezing 165, embryo replacement 166, and development tobirth 168.

For convenience, we briefly discuss certain terms that we use in ourdescription.

When we use the term superovulation, as shown, for example, as element152 in FIG. 1, we intend to refer broadly to any production and releaseof many (for example, three or more) mature eggs 124 in one menstrualcycle, triggered, for example, by a medication that stimulates theovaries.

When we use the term artificial insemination (AI), as shown, forexample, as element 154 in FIG. 2a , we include broadly any process bywhich sperm 128 is placed into the reproductive tract of a woman, forthe purpose of impregnating her, by other than sexual intercourse. Insome examples, the artificial insemination 154 involves placing sperm,which has been processed by washing her partner's semen, into theuterine cavity 126, and is sometimes called artificial intrauterineinsemination 126, 154 (IUI), for example, as shown in FIG. 2a . When IUIis combined with a sequence of injectable fertility drugs, there is anexpected marked increase in pregnancy rates compared to insemination bysexual intercourse and spontaneous ovulation.

We use the term in vivo fertilization broadly to include anyfertilization within a woman's body, for example, the naturalcombination of an oocyte (egg) 124 and sperm 128 in the femalereproductive tract that occurs as a result of sexual intercourse orafter artificial insemination.

We use the term in vitro fertilization (IVF) to refer broadly to anyfertilization that occurs outside of the woman's body, for example, whenthe oocyte and the sperm are combined in a laboratory dish. In someexamples, the fertilized oocyte is incubated for 3 to 5 days in achamber (incubator) that provides warmth and nutrients. After IVF, theembryo 88 may be implanted into the uterus of a woman to carry the babyto term. IVF tends to be complex, inefficient, and expensive. Typically,the oocyte is recovered in an operating room under general anesthesiaand is fertilized by injecting sperm (for example, ICSI:intracytoplasmic sperm injection) in a sophisticated laboratoryfacility. Live birth rates for PGD done by IVF normally run between 20to 30% per treatment cycle; these rates are improving only modestly inrecent years and are not expected to improve dramatically in theforeseeable future.

We use the term blastocyst to refer broadly to, for example, any humanpreimplantation embryo when it is in a developmental stage, for example,a stage that is typically reached at 4-5 days after fertilization and isobservable in the uterus for up to 8 days after fertilization and justprior to implantation. A human blastocyst normally consists of 100 to300 cells and is a thin-walled embryonic structure that contains apartially differentiated cluster of cells called the inner cell massfrom which the embryo arises. An outer layer of cells gives rise to theplacenta and other supporting tissues needed for fetal developmentwithin the uterus, while the inner cell mass cells give rise to thetissues of the body. Located at the center of the blastocyst is afluid-filled or gel-filled, hollow center or core called the blastocoel.The blastocoel core and the gel or fluid that comprises it comes intodirect physical contact with the trophectoderm or inner cell mass cellsthat make up the blastocyst walls that surround that core. Humanblastocysts, if removed from the woman, produce high singleton pregnancyrates when transferred back into the uterus and are considered to be ata good stage for preimplantation diagnosis, because there are many cellsand a high likelihood of survival. In our discussion, the termsblastocyst and embryo are commonly used interchangeably.

When we refer to a catheter, we mean to refer broadly to, for example,any hollow tube that has any shape, form, weight, material,configuration, size, rigidity, durability, or other characteristics tobe inserted into the uterus to permit fluid to pass to or from theuterus.

The term uterus as shown, for example, in FIG. 9 refers to a hollow,muscular, pear-shaped organ, located in a pelvis of a woman between thebladder and the rectum where pregnancy implants, grows and is carried toviability.

We use the term cervix as shown, for example, as element 90 in FIG. 9 torefer broadly to the lower, narrow segment of the uterus that embracesat its center an endocervical canal 157 connecting the uterine cavitywith the vagina. The cervix typically is dilated (that is, the canalmust be expanded or enlarged) to pass the instruments required foruterine lavage or for transfer of embryos back into the uterus.

We use the term fundus as shown, for example, as element 153 in FIG. 9to refer broadly to all parts of the uterus and its cavity that aredistal to the cervix and extend to and include the internal openings tothe fallopian tubes.

We use the term uterine cavity broadly to describe the heart-shapedspace shown, for example, as element 126 in an anterior-posterior viewin FIG. 9. Viewed as a lateral exposure as in FIG. 10, the uterinecavity 126 between the cervical canal and the Fallopian tubes appears asa narrow slit. The uterine cavity space represents a potential space inthe non-pregnant state, when the muscular front and rear (anterior andposterior) uterine walls are in direct contact with each other andseparated only by a thin film of uterine fluid. The direct apposition of(contact between) the anterior and posterior walls of the uterine cavity126 is apparent in the lateral view in FIG. 10. Blastocysts and otherpreimplantation embryos are freely suspended in this film ofintrauterine fluid before they implant into the wall of the uterus. Thepotential space becomes a real space when greatly expanded when, forexample, the walls are separated 127 mechanically by surgicalinstruments (such as catheters) or in the pregnant state when thepregnancy and its surrounding membranes separate the walls widely apartas in FIG. 11.

We use the term Fallopian tube as shown, for example, as element 86 inFIG. 9 broadly to describe oviduct structures that enable, for example,transport of sperm cells from the uterus to the ovaries wherefertilization takes place and for return transport of embryos back tothe uterus for implantation.

Internal ostia refers broadly to openings in the uppermost uterinecavity that link and complete the passageway of the Fallopian tubes fromthe ovaries to the uterus as shown, for example, as elements 104, 106,in FIG. 9.

The term internal os refers to the opening of the cervix into theuterine cavity as shown, for example, as element 155 in FIG. 9.

The term external os refers to the opening of the cervix into the vaginaas shown, for example, as element 170 in FIG. 9.

As we use the term, cryopreservation refers broadly to a process inwhich, for example, one or more cells, whole tissues, or preimplantationembryos are preserved by cooling to a temperature at which, for example,biological activity including biochemical reactions that would lead tocell death, are slowed significantly or stopped. The temperature couldbe a sub-zero ° C. temperature, for example, 77° K or −196° C. (theboiling point of liquid nitrogen). Human embryos can be cryopreservedand thawed with a high probability of viability after storage even ofmany years.

When we refer to intervention by embryo (gene) therapy, for example, asshown as element 164 in FIG. 8, we intend to include broadly anystrategy for altering a human physical condition, including, forexample, treating a disease by placing (e.g., injecting) cells into anembryo, blastocyst or its blastocoele core, or placing (e.g., injecting)DNA (such as modified or reconstructed DNA) into individual embryoniccells or inner cell mass or trophectoderm cells or surrounding media soas to modify the genome of the embryo or blastocyst to correct, forexample, a defective gene or genome.

In a general strategy, gene therapy at the embryonic blastocyst stagemay involve replacing a defective gene of any genetic disease with anintact and normally functioning version of that gene. Replacement isperformed by placing the replacement gene in the surrounding media orinjecting the replacement gene by nanosurgical methods directly into theblastocoele of a blastocyst or selectively into its trophectoderm cellsor inner cell mass.

In one strategy, the replacement gene or DNA sequence can be loaded ontoa virus (for example retrovirus or adenovirus vector) which delivers thesequence into the trophectoderm cells or cells of the inner cell mass.Other intracellular delivery methods include use of other viruses andnon-viral methods including naked DNA, chemical complexes of DNA orphysical methods such as electroporation, sonoporation, ormagnetofection.

The blastocyst is an excellent (perhaps ideal) site to implement genetherapy because the genetic constructs and viral vectors are likely notdestroyed by the immunological response of an adult organism that mayimpair the success of gene therapy when applied to adults. Thus it isexpected that incorporation of replacement genes and their viral vectorswill be highly efficient at the blastocyst stage.

One example would be prevention or deletion or inactivation of theHemophilia B gene in a human blastocyst Hemophilia B male carrier byinjection of the replacement gene with an adenovirus vector into thesurrounding media or blastocoel core allowing vector to contact andtransfect virtually all trophectoderm and inner mass cells and beincorporated ultimately into all fetal and adult cells of the resultingnewborn. Hemophilia B has been successfully treated in adult humansubjects by gene therapy.

We use the term fertile couple to refer broadly to a man and a woman whohave no known fertility disorders (for example, a biological inabilityof one of them to contribute to conception). Conversely, we use the terminfertile couple to refer broadly to a man and a woman known to have afertility disorder, for example a disorder in which unprotected sexualintercourse for over one year fails to achieve a viable pregnancy if thewoman is 35 years old or less or six months of unprotected intercourseif 36 years old or older.

We use the term lavage fluid to refer broadly to any physiologic fluidthat can be used in the process of recovering blastocysts from theuterus, for example, a wide variety of aqueous tissue-culturelife-sustaining buffered salt solutions (media) (for example—Heapesbased HTF with 20% protein) commonly used in embryology laboratories tosustain embryonic viability for long or short periods of time.

We use the term lavage fluid filtering broadly to refer to any kind ofprocessing of uterine lavage fluid (for example, after it has beenrecovered from the uterus) to, for example, isolate human blastocystsfrom the fluid. Such filtering can include, for example, separatingmaternal intrauterine cells, mucous, and debris from the blastocysts.

We use the term preimplantation embryo to refer in a broad sense to, forexample, an embryo that is free floating in a woman's reproductive tractafter fertilization. A preimplantation embryo can have, for example, onecell with a male and female pronuclear (day 0) graduating to two cells(day 1) to 2-4 cells (on day 2) to 6-10 cells (day 3), to blastocysts(day 5 to 8) with 100 to 300 cells. Typically, a pregnancy isestablished when a preimplantation embryo implants into the uterine wallon day 7 or 8 and begins to interact with the maternal blood supply.

We use the phrase preimplantation genetic diagnosis (PGD) broadly torefer, for example (element 162 in FIG. 8), to any kind of geneticdiagnosis of embryos prior to implantation. PGD can, for example, reducethe need for selective pregnancy termination based on pre nataldiagnosis as the method makes it highly likely that the baby will befree of the disease under consideration. In the current practice, PGDuses in vitro fertilization to obtain oocytes or embryos for evaluation.More broadly, although sex determination does not necessarily implydisease, we include in genetic diagnosis the possibility of sexdetermination of the embryo.

We use the phrase pre-implantation genetic screening (PGS) broadly todenote, for example, procedures that do not look for a specific diseasebut use PGD techniques to identify embryos at risk. An early-stageembryo has no symptoms of disease. To “screen” means, for example, totest for anatomical, physiological, or genetic conditions in the absenceof symptoms of disease. So both PGD and PGS may be referred to as typesof embryo screening.

When we use the term uterine lavage (examples shown in FIGS. 3, 4, 8),we intend to refer broadly to any possible lavage technique for recoveryof one or more human embryos (e.g., blastocysts) from a living healthywoman after formation of the embryos, for example, before the embryoshave established a pregnancy by attachment to the uterus. In someexamples, the lavage includes flushing fluid, for example, cell culturefluid, into the uterus and capturing the flushed fluid from the uterusto recover the blastocysts.

When we use the term recovery in reference to blastocysts, we intend toinclude broadly any process of any kind, form, duration, location,frequency, complexity, simplicity, or other characteristic that is usedto retrieve one or more blastocysts from a woman.

The term recovery efficiency refers broadly to, for example, the numberof blastocysts recovered (e.g., by uterine lavage) from a womanexpressed as a percentage of a total number of blastocysts expected tobe recovered based on the number of blastocysts that actually resultfrom a superovulation cycle. It is possible to estimate the number ofblastocysts that will result from a superovulation cycle relativelyaccurately by using ultrasound to image the ovaries and counting thenumber of mature follicles that are expected to release eggs. The numberof blastocysts and unfertilized eggs recovered during lavage can also becounted directly in the recovered fluid. The ratio of the number ofrecovered blastocysts to the number expected to be released yields therecovery efficiency.

Younger women (under age 35 years) with normal reproductive efficiencyare expected to produce from 1 to 5 healthy blastocysts persuperovulated cycle, and the expected recovery efficiency for thoseblastocysts is at least 95%-100%, or in some cases at least 95% or insome cases at least 90% or in some cases at least 80% or in some casesat least 50%. Recovery efficiency is expected to decrease with advancingmaternal age, and applying the techniques described here for more thanone ovulation cycle is expected to be required for older women or womenwith borderline fertility.

It may be desirable to adjust the parameters and approach to theprocedures that we have described here to achieve the greatest possiblerecovery efficiency. Achieving a high recovery efficiency is bothadvantageous to the woman because it implies that fewer blastocysts willremain in the uterus that could potentially implant. High recoveryefficiency is also desirable because it will improve the statisticallikelihood that, among the blastocysts recovered, one or more will besuitable for treatment (or will not need treatment) and can be readimplanted in the woman, without requiring repetitions of the procedure.In this sense, higher recovery efficiency will also mean lower cost.

As we have described here, appropriate treatments delivered to the womanat the appropriate times can reduce or eliminate the chance of anyunintended implantation of a blastocyst that has not been recoveredduring the lavage.

In some cases we expect to achieve 100% recovery efficiency, but anyrecovery efficiency of 50% or more is expected to be desirable anduseful. Commercial viability of the procedure is expected to be good ifthe recovery efficiency can be at least 80% or at least 90%. Recoveryefficiency of at least 95% should provide excellent commercialfeasibility possibilities.

The terms GnRH (gonadotropins releasing hormone) antagonist or agonistare used broadly to refer, for example, to a class of modified centralnervous system neurohormones that are used as injectable drugs tostimulate or shut down release of pituitary hormones (e.g., FSH) thatregulate human ovulation and release of ovarian hormones.

The term FSH (follicle stimulating hormone) refers to a pituitaryhormone that naturally regulates the maturation and release of ovarianfollicles and oocytes. Injected as a therapeutic agent, FSH canstimulate the maturation of multiple oocytes.

The term LH refers (luteinizing hormone) refers to a pituitary hormonethat naturally induces the release of oocytes at ovulation. Injected astherapeutic agent, LH (or various surrogates) can induce release ofoocytes at ovulation at a time determined by the time of injection.

We now describe in overview the process of uterine lavage fromsuperovulation to embryo recovery, embryo management, and uterinereplacement of selected or treated in vivo embryos. In some examples,the process is implemented in nine steps described below and shown inFIGS. 1-8.

Superovulation 152 (FIG. 8b ) is induced using injectable FSH 224 tostimulate maturation of multiple oocytes. Injectable GnRH agonist, LH orhCG, or an LH surrogate (which stimulates the pituitary to secretenatural LH) is then used to trigger the superovulation (the release ofmultiple unfertilized oocytes 124 from both of the ovaries 122). FSH iscombined with GnRH agonists 218 or antagonists 220 to quiet the ovaries122 into a pseudo-menopause state. In some implementations, one or moreof these steps used for in vivo fertilization are similar to, but notexactly the same as, those used to induce superovulation by fertilityclinics for IVF cycles. For in vivo fertilization, standard IVFsuperovulation methods, for example, are highly modified to reduce risksof ovarian hyperstimulation and retained pregnancies resulting fromblastocysts not recovered in the uterine lavage.

In some implementations (FIG. 8b ), the modifications include that thesuperovulation cycles use GnRH antagonists 220 (GnRH receptor blockerpeptides such as CETROTIDE 0.25 to 3 mg, GANIRELIX, ABARELIX,CETRORELIX, or DEGARELIX) to quiet the ovaries during stimulation withFSH. The FSH 224 stimulates maturation of multiple oocytes. In someinstances, FSH is self-injected using daily (5 to 15 daily injectionsgiven at ranges of 37.5 to 600 mIU per day) doses of FSH (preparationsincluding injectable menotropins containing both FSH and LH, purifiedFSH given as urofollitropins, or recombinant pure FSH) or single dosesof long acting pure FSH (recombinant depo FSH).

In some implementations, a single subcutaneous dose (e.g. 0.5 mg) ofGnRH agonist 218 (GnRH analog Leuprorelin or Leuprolide acetate orNafarelin or Nafarelin Acetate snuff or Buserelin) is injected orsnuffed (which releases endogenous LH) to trigger the superovulation 152(released of multiple oocytes). Compared to traditional methods oftriggering superovulation, the GnRH agonist 218 trigger minimizes riskof hyperstimulation because the release of the patient's own pituitaryLH is short lived and the released natural LH has a short half-life(dissipates quickly). The GnRH agonist trigger will only minimallyaggravate continued hyperstimulation of a superovulated ovary.

In some implementations, traditional LH 222 (injectable recombinantluteinizing hormone or LH) or hCG 223, may be used without GnRH agonistor in combination with agonist in some cases if release of endogenouspituitary LH is not adequate.

In some implementations, because there is risk of corpus luteumapoptosis (collapse) with antagonist suppressed cycles, progesterone 228(given as vaginal progesterone, Crinone® 1 application per day orPrometrium® 200 mg 3 applications per day) or oral progesterone 228 (orPrometrium® 200 mg 3 oral capsules per day) and oral or transdermalestradiol 230 (transdermal estradiol patches 400 ug per day or oralestradiol 4.0 mg per day) are administered until the day of lavage.

In some implementations, after lavage, both progesterone and estradiolare discontinued. Uterine lavage is performed between days 5 and 8 andthe embryos are recovered. At the end of the lavage, before or shortlyafter removal of the catheters, a single dose of progesterone receptorantagonist 226 (Mifepristone 600 mg) is injected into the uterine cavitywith a second dose (Mifepristone 600 mg) mg given by mouth one day priorto expected menses.

In some implementations, after lavage, GnRH antagonist 220 isadministered (e.g. CETROTIDE 3 mg) on the day of lavage recovery toinduce corpus luteum apoptosis and suppress luteal phase progesteroneand decrease further risk of a retained (on account of blastocystsmissed by the intrauterine lavage) pregnancy. GnRH antagonistadministration starts before or on the day of lavage recovery and maycontinue daily utilizing dosages of about 0.25 to 10 mg for up to 10days following lavage. This novel use of a GnRH antagonist for corpusluteum suppression following blastocyst recovery after superovulationreduces or eliminates the possibility that unrecovered blastocysts willimplant and result in unintended pregnancy. Uterine lavage done onnon-stimulated cycles has a significantly lower risk of retained and/orectopic pregnancy.

As explained, because the superovulation and artificial inseminationproduce viable multiple blastocysts within the uterus, and because thelavage may possibly not recover all of the blastocysts from the uterus,it is important to take steps, such as though mentioned above, to reduceor eliminate the possibility that unrecovered blastocysts will implantand result in unintended pregnancy.

Although examples of protocols for achieving superovulation and stepsthat follow it are described above, a variety of other protocols may besafe and effective. Other protocols may be able to achieve the functionsand results mentioned. For example, other regimes may be possible toquiet the ovaries into a pseudo-menopausal state, to trigger maturationof multiple oocytes, to stimulate superovulation, to minimize the riskof overstimulation, to reduce the risk of collapse, and in general toreduce the risk of an unintended retained pregnancy.

The released oocytes 124 are captured in the open end of the Fallopiantube 86 and move towards the uterine cavity 126 naturally afterovulation (FIGS. 1-2).

The oocytes 124 are fertilized in the woman's Fallopian tubes 86 or inthe area 89 peritubal-ovarian interface adjacent to the ovary where thetubes open in contact with or in close approximation to the ovary (FIGS.1, 2).

Approximately 90% of reproductive age couples should be ablesuccessfully to undergo superovulation with uterine lavage for embryorecovery. Approximately 10% of couples will be infertile and shouldundergo preimplantation diagnosis by in vitro fertilization.

As shown in FIG. 2, artificial intrauterine insemination (IUI) isperformed using an ordinary commercially available intrauterineinsemination catheter 130 to inject washed semen 128 through the vagina92 and cervix 90 directly into the uterine cavity 126 one time persuperovulatory cycle. IUI is performed after superovulation, 36 hoursafter triggering this event with the GnRH agonist and/or hCG or LHsurrogate. This IUI procedure delivers sperm 128 cells into the uterusthat then become available in very large numbers for in vivofertilization.

In vivo fertilization (FIG. 2a ) occurs by natural means afterartificial insemination with washed semen 128. The sperm cells 128migrate to and through the internal ostia 104, 106 into the oviducts 86migrating to the distal oviduct 87 into the peritubal-ovarian interface89 in contact with and adjacent to the ovary 158 where sperm cellscontact and interact with the released oocytes 124 to fertilize theseoocytes 124 in vivo.

In vivo fertilization (FIGS. 2, 3) in the woman's reproductive tractoccurs naturally after artificial intrauterine insemination (IUI).Typically the sperm 128 travel up the Fallopian tube toward andfertilize the oocytes, which then become embryos 124. The embryos 88(FIGS. 3, 9, 10) then continue to move toward and into the uterinecavity 126 where by the fifth to sixth day they mature to blastocysts 88and are free floating in a thin film of uterine fluid between theanterior and posterior surfaces of the middle uterine cavity. (126,161).

The section broadly reviews the clinical strategy of uterine lavage andits role in embryo recovery. Technical details of some implementationsof devices, catheters, maneuvers for deploying them, and supportapparatus for performance of uterine lavage and embryo recovery aredescribed in text associated with FIGS. 13-64 e

Here we provide a brief summary of uterine lavage.

The lavage begins.

With a suction cannula 16 and collapsed funnel balloon 44 in place underultrasound guidance (FIG. 3), the operator (for example, a speciallytrained technician or nurse) inserts and steers one or two fluid supplycatheters 64, 66 into the uterine cavity (FIGS. 3, 4). The lavagecontroller connected to the system is prompted to begin the lavage withpreset delivery frequencies of lavage fluid and collection of embryosinto a suction (or aspiration) trap 28.

The lavage cycle is started when the controller is prompted to begin thepreset lavage cycle of pulsed fluid delivery and collection cycles. Thefirst stage of the lavage cycle is begun by injecting a small amount offluid into the uterine cavity to form a puddle of fluid encompassing thepre-implantation embryos. All of the fluid present in the uterine cavityis then suctioned into the system with one or more entrainedpre-implantation embryos. The second stage of the lavage cycle is begunby injecting a larger amount of fluid into the uterus to form a largerpuddle. All of the fluid present in the uterine cavity is then suctionedinto the catheter along with one or more entrained embryos.

The uterine lavage procedure is performed under low flow and vacuumconditions, as managed by the controller, not to exceed the maximumpressure allowed by the device of between 2 ounces per square inch and20 pounds of pressure per square inch and 2-30 in Hg of vacuum pressureto maintain the integrity of the blastocysts during fluid removal andremoval. The uterine cavity is not expanded or pressurized. The lavagedevice does not include any members that act to expand the uterinecavity; as such an expansion can introduce air into the uterine cavity,which can kill blastocysts. The lavage process was designed to preventthe introduction of air into the uterine cavity to ensure the health andintegrity of the recovered blastocysts.

We now outline briefly two examples of uterine lavage techniques andapparatus described in substantial detail in sections dealing with FIGS.13-64 e.

In one example approach, a single fluid supply line (catheter) 20 (whichwe sometimes refer to as version #1) is steered with ultrasound guidanceto the top of the uterine cavity 126. A more complete description of theone uterine supply line catheter (version #1) system is given in textdealing with FIGS. 13-64 e.

In a second example approach, dual fluid supply catheters 64, 66 (FIG.4) (which we sometimes call version #2) are steered with ultrasoundguidance individually both superiorly and laterally 94 inside theuterine cavity along the right and left uterine sidewalls 94, 98 to thetop of the uterine cavity 127. In one example (version #2b) the twocatheters snap together magnetically at the top of the uterine cavity toform a mechanical hydraulic perimeter around the embryos (FIG. 4). Amore complete description of the double supply line catheters (version#2b) system showing steerage and placement is given in text dealing withFIGS. 36-64 e

Lavage fluid is collected in a non-embryotoxic glass recovery trap 28 atvolumes expected to be in a range of 5 and 100 cc's. The lavage fluid isthen diluted in additional physiologic transport media (forexample—Heapes based HTF with 20% protein), and the resulting mixturecontaining embryos is sealed in the collection transport trap 28 b witha tightly fitting glass 33 non perforated stopper. The collection trap28 a, after sealing, thus becomes the transport vial 28 b for transportto the core embryology laboratory. The transport vial 28 b (FIG. 14b )will maintain viability in excess of 24 hours. The transport vial 28 bcontaining embryos, secured within an anti-shock insulated transportblock 31, is then transported in a secure carrying case 190 to thecentral embryological laboratory by hand or overnight air transport.

In another iteration, lavage fluid may be collected directly into acell-culture system capable of maintaining blastocyst viability duringshipment to the central embryological laboratory. Such a system wouldmaintain blastocyst-safe O2/CO2 levels without the requirement of anincubator and eliminate the need to dilute lavage fluid with physiologictransport media thus streamlining the recovery and shipment ofpre-implantation embryo captured through uterine lavage.

Embryos are recovered in the central embryological laboratory 174.

On arrival in the embryology laboratory, the transported lavage fluid ispassed from the transport vial 28 b through a filter 37, 39 to removecells and debris and into a large flat petri dish 28 c where it isscanned by an embryologist using a standard binocular microscope.Scanning devices to automate this step are under development. Theblastocysts are recovered by the embryologist using embryological glasspipettes and transferred individually into smaller individualembryological culture (Petri dishes) 28 d containing standard embryotissue culture fluid buffered for stability, e.g. Gardner's G-2.2 media)

Utilizing a micromanipulation apparatus, individual blastocysts 88 arepositioned in side their individual Petri dishes under blastocystculture fluid onto the tip of a fire-polished pipette 136 and stabilizedby application of gentle suction on the lumen of the pipette. The zonepellucida (FIG. 5) is opened mechanically with another pipette 138 orwith a laser beam to expose either the trophectoderm (futureplacenta—134) or inner cell mass (future fetus—135) of the blastocysts.It is likely that with existing or future nano surgical technology itwill be possible to remove from one to many targeted cells 134, 135 formolecular genetic diagnosis or sex determination.

Trophectoderm cells 134 (early placenta) or early fetal cells 135 (innercell mass) obtained from targeted embryonic regions are placed inblastocyst media in petri dishes or small tubes 28 c and then undergomolecular genetic diagnosis or sex determination or both. Molecularmethods are selected for the condition being evaluated. Establishedtechniques include one or more of (or combinations of any two or moreof: in situ hybridization 148 (FIG. 6) to evaluate chromosomalstructures, polymerase chain reaction directed to detect specificmutations or other defects gene organization, whole genomehybridization, microarray gene chips, exome sequencing, or analysis ofthe entire human genome. A geneticist evaluates the molecular analysisin combination with information about specific clinical factors of thecase. A decision is then made that leads to (a) replacing the embryo inthe mother, as unaffected by the disease in question, (b) recommendingan intervention such as gene therapy or transplantation of donated stemcells, or (c) recommending that the embryo not be replaced and thatanother embryo which is unaffected be replaced at a later time.

A common example of a molecular diagnosis (Down syndrome) 146 currentlypossible from human blastocysts using either single trophectoderm 134 orvery early fetal cells is illustrated in FIG. 6. This figure depicts anexample in which specific areas of chromosomes are targeted at amolecular level fluorescent in situ hybrization (FISH) 148 withfluorochromes, which produce a microscopically visible signal whenlinked. In this example (FIG. 6), a diagnosis of Down syndrome isdemonstrated by the presence of three #21 chromosome signals 146. Alsoseen are two X-signals 140 indicating female gender, two (#18)-signals142, two (#13) signals 144 and two (#18) 142 signals as would beencountered normally.

Other molecular methods, besides FISH, available for detection ofspecific single mutations or groups of mutations, include polymerasechain reaction, whole genome hybridization, microarray gene chips, exomesequencing, and analysis of the entire genome. Any one or two or more ofthese in combination could be applied. When the result is available, ageneticist evaluates the molecular analysis, including combining theinformation with specific clinical factors unique to the family that ledto the indication for preimplantation diagnosis in that embryo. Adecision is then made to replace the embryo 132 in the woman (FIG. 7) ifit is unaffected by a disease in question, to recommend an interventionsuch as gene therapy or transplantation donated stem cells, or torecommend that the embryo not be replaced and that another embryo, whichis unaffected, be replaced from another procedure.

With current technology, the identification of many hundreds ofchildhood and adult diseases at the molecular genetic level in single ora few trophectoderm 134 cells is possible. In the future, the varietiesof single cell diagnoses will expand into the thousands as increasingknowledge of the molecular bases of common multigenic disorders expands.This list likely will include disorders such as schizophrenia, autism,diabetes, coronary artery disease, malignancies, and many others. Aspublic awareness of the molecular bases of common diseases becomescommonplace, the occurrence of these problems in yet to be born childrenand will be of major concern. There is likely to be substantial demandfor this information in yet to be born children.

A variety of therapeutic scenarios will become available with advancesin molecular genetic technology, including the three following examples.

1. PGD allows for identification of embryos that are carriers of geneticdisorders or of desired genetic traits. PGD facilitates selection of theunaffected or carrier embryos for transfer to (replacement in) theuterus. Embryos afflicted with the genetic disease in question are notreplaced in the uterus and are discarded. PGD allows identification ofembryonic sex. Embryonic sex selection may be used for prevention ofsex-linked genetic diseases. Sex selection may also be used for culture,social indications, or family balancing by gender/sex or any combinationof them.

2. Embryonic gene and stem cell therapy has been achieved inexperimental and domestic animals, in human adults and children, but notyet at the human embryonic stage. Gene and stem cell therapy targeted atthe preimplantation embryo is especially promising because it repairscells with abnormal genetics before differentiation of the cells, byadding to, replacing, or manipulating (or a combination of them) adysfunctional sequence of DNA. Also, human gene therapy may readily bedelivered by blastocoel injection because blastocoel gel comes intodirect contact with virtually all cells. Human gene therapy at theblastocyst stage though not yet achieved, is foreseeable in the future,particularly with recent adult human successes with treatment of geneticdiseases by gene therapy, e.g. Hemophilia B.

One technique potentially useful at the blastocyst stage is to remove afew stem cells from the inner cell mass, transfect the cells directlyusing a retroviral vector or by actual micro insertion of the constructinto the isolated stem cell. Once the correction is incorporated intothe genome of the stem cell, it can be reintroduced back to the innercell mass where it would be incorporated into the growing embryo. Sincethe transected stem cells are totipotential, the corrected genetics canbe incorporated into any organ including germ cells then transmitted tofuture generations.

3. Embryos suitable for replacement in the uterus, either because theyare genetically unaffected or have been successfully treated, arecryopreserved 165 for transfer either in the following spontaneousmenstrual cycles or at a more remote future date.

Following cryopreservation, embryos suitable for replacement are thawedand transferred back into the uterine cavity 126 (FIG. 7). To do this,the embryo is suspended in tissue culture fluid. The fluid is loadedinto an embryo transfer 150 catheter. This catheter can be any one ofmany commercially available device widely used for embryo transfer infertility clinics for this purpose. The embryo transfer catheter ispassed through the cervix by the same technique commonly used infertility clinics for in vitro fertilization. The embryo 132 is placedinto the geometric center of the uterine cavity, as determined byultrasound and external markings of the catheter tubing. By naturalprocesses, the embryo free-floats 132 in a film of uterine fluid withinthe uterine cavity 126, 161 for approximately another 24 hours and thenattaches to the uterine wall at the center of the uterine cavity 88,126, 161. The embryo ultimately implants in the uterine lining 82(endometrium), accesses the maternal blood supply, and then develops fora normal gestation period resulting in the birth of a newborn free ofthe genetic disorder under treatment.

We have described examples of the procedure in a series of stepsperformed on a single patient. In making this procedure available to avery large number of patients all over the world (including in large andsmall communities, and in rural and urban areas), techniques can appliedto reduce the cost, improve the safety, and enhance the efficiency andperformance of the procedure, among other things. One or moreappropriate business models can be used to provide these advantages topatients while offering revenue and profit opportunities formanufacturers and distributers of the devices used in the procedure,providers of the services that are part of or associated with theprocedure (including PGD, genetic disease prevention, embryonic genetherapy, and stem cell transplantation), medical professionals, andother parties. The business model can include a variety of transactionalfeatures including sale, rental, and licensing of devices and equipment,fees for services, licensing of services, and others.

Shown in FIG. 12 are some examples of how the procedures would bedelivered and managed. A corporate managed regional coordination center172 (also sometimes called the host of the network) would own and manageor franchise the operation of a number of core laboratories 174 (onlyone shown) located in high-density population centers across the UnitedStates. Location of each of these laboratories is based upon a servicearea 176 that is within a defined surface travel time or distance of thelaboratory. For example, a service area could be one served by groundtransportation of a distance of approximately 150 miles radius or lessthan 4 hours transportation time from the laboratory, or with reliabledelivery by air to the laboratory within a flight time of less than 4hours. Examples of suitable cities (Table 1) could include New York (2centers), San Francisco, Los Angeles, Boston, Chicago, Philadelphia,Washington DC, Seattle, Minneapolis, Miami, Atlanta, Denver, Dallas,Phoenix, and Memphis.

TABLE 1 Core Network laboratory locations 174 within surfacetransportation of 4 hour or less or 4-hour direct airfreight servicesfrom network subscriber clinics. Center Population/Square Mile 1. NewYork (2 centers) 26,821 2. San Francisco 17,179 3. Boston 12,792 4.Chicago 11,841 5. Philadelphia 11,379 6. Washington DC 9,856 7. Seattle7,250 8. Minneapolis 7,019 9. Miami 5,878 10. Atlanta 4,019 11. Denver3,698 12. Dallas 3,517 13. Phoenix 2,797 14. Memphis 2,053 (FedEx 4 hournight service all USA)

In some implementations, each of the core laboratories 174 (FIG. 12)will be imbedded in an existing embryological molecular genetic servicelaboratory already existing in a major, high profile medical center.Each of the core laboratories would be supported and electronicallylinked to its own regional network of subscriber clinics 178 andembryology laboratories 179. The host of the network will lease orpartner with existing core laboratories capable of providing embryology,cryogenic, and molecular genetic services (or some part of them) forembryos acquired in their service areas same day.

The network host's subscriber clinics 178 (FIG. 12) are points ofpatient contact and care services. The network host will lease orpartner with a regional network of such local subscriber clinics, which,in some examples, are similar to reproductive medicine and geneticscenters that operate today. Subscriber clinics 178 are the sites wherepatient interactions take place. Physicians and support staff working inthese local clinics will be subscribers to the network host's systems.Among other things, to become a subscriber a clinic will have to includehigh security areas 179 in their clinics and computer linkages 181 thatare managed by the network host 172 and devoted solely to network hostoperations at their site. Physicians and support staffs working insubscriber clinics 178 will all have been previously established aspractitioners of reproductive endocrinology, infertility, and genetics.

Patients 183 seeking the network host's services are referred to asubscriber clinic located near their home or business. There need beonly limited disruption of a patient's personal life while she isreceiving services in the system. The ordering of the central host'sembryological services, genetic testing, and obtaining of results willbe as simple as ordering routine laboratory testing as practiced today.

We now review the process as would be seen and experienced by anindividual patient 183.

The process begins with patient 183 entry at a local network subscriberclinic 178 and ends with embryo recovery at the clinic, followed byembryo diagnosis, decision, treatment if possible, and replacement ofher embryos at the subscriber clinic 178 (FIG. 12). The steps ofcounseling, consenting, superovulation, artificial insemination, andlavage take place in subscriber clinics 178 under the direction of theclinic physician and staff Network personnel perform lavage, transport,and processing of her embryos at the core laboratory 174, to return andtransfer of her unaffected embryos back at the subscriber clinic 178, tofollow-up and confirmation of her unaffected pregnancy in her localhealth care system.

Patient 183 entry begins at the subscriber clinic 178 where she and herpartner have been referred by herself or by a physician in anticipationof her becoming pregnant. The family may be aware of that clinic bylocal reputation of that clinic as a provider of the network'stechnology. It will also be well known on the Internet. After review ofthe genetic reproductive history, a subscriber's reproductiveendocrinologist geneticist will make the decision that the network'sprocedure is appropriate and will contact the network's core laboratorythrough their subscriber link. The patient's data will be enteredlocally at the subscriber clinic 178 along with appropriatedemographics, financial, and insurance data.

The network regional coordinating center 172 will review the dataentries and, as appropriate, approve of that patient's entry afterreview of history and laboratory data.

The network's nurse practitioner staff will see the patient in person atthe subscriber clinic, customize and fit the lavage catheters to thespecific anatomy of that patient using traditional or 3D ultrasoundimaging, and approve her for launch (starting superovulatory drugs) ofher cycle.

The network's regional coordinating center 172 will then authorizeinitiation of the drug induced superovulation induction. Subscriberclinic physicians will prescribe and administer superovulatory drugsunder protocol, conduct the monitoring, and report the patient'sprogress in real time using online links to the network's regionalcoordinating center.

Superovulation (actual release of oocytes for fertilization) will betriggered by protocol and managed by subscriber clinic physicians. Thewoman will then appear in the subscriber clinic 178 with her partner,and after documenting security clearance using electronic chips andface-iris recognition (in other words, confirming that the woman is theperson who she purports to be and is the patient to be processed), thesubscriber clinic personnel, with approval by the network regionalcoordinating center 172, will perform intrauterine insemination of thewoman at approximately 36 hours after triggered superovulation. Spermsamples will be prepared in the onsite network secure laboratory site178 with identities reconfirmed electronically by the patient's and herpartner's electronic identification cards that are programmed withconfirmatory facial recognitions and iris scans.

Uterine lavage will be performed at the subscriber clinic by the networknurse practitioner at between 5 and 7 days after insemination. Therecovery fluid is diluted with embryo protective transport media addedimmediately to the lavage fluid at recovery and is transported in sealedinsulated containers 28 b 31 (FIG. 13b ) that are marked by electronicidentification chips 189 (FIG. 13e ) linked to the women 183,189 and herpartner 183 (FIG. 12).

After lavage, the subscriber clinic 178 will electronically notify thecore laboratory 174 by way of the secure computer network link of thestatus and location of all blastocysts in process in the network at thattime. At each step in the process after lavage, information will berecorded electronically as identity chips attached to each clinical andlaboratory step are scanned and stored in the network system dataprocessing facilities to maintain a history of the steps and the currentlocation of the embryos. Thus, the exact location of all embryos andcells retrieved from all patients will be known in real time asidentification chips are passed through scanners from lavage, torecovery in the laboratory, to biopsy, to genetic diagnosis, genetictherapy, or sex determination (or any two or more of those), tofreezing, thawing, and replacement back into the patient. The identityof all patients and their partners will be confirmed by iris/retinascans, electronic face recognition, and identification cards at eachcontact. Software will also be used to manage lab reports, clinical datafrom each patient and her partner, contact information, and billing andinsurance arrangements.

Embryos are delivered to the core laboratory in the same lavage fluid,diluted in transport media that was used for the lavage recovery. Thecontainers 28 b in their insulated transport blocks 31 obtained from theday's procedures are carried in secure carrying cases 190 transported bythe nurse practitioner. On arrival at the core laboratory and ondelivery to the secure network laboratory space 192, the lavagecontainers 28 b are matched electronically after scanning to theidentification system and then placed in an individual space 192 (shownin the FIG. 13b ) allocated only to those embryos. The identificationdatabase 194 (shown in the FIG. 12) maintained in the corporate regionalcoordinating center 172 contains all instructions on the type of biopsyprocedure to be performed, and the diagnostic tests to be performed onthe biopsied cells relevant to that patient.

After the embryologist manually isolates and confirms identify from scanof the electronic chip attached the transport container 28 b, eachembryo is graded for viability by embryologists, placed on amicromanipulator in it its electronically marked petri dish, andundergoes selective trophectoderm-inner cell mass biopsy. Approximately10 to 20 trophectoderm 134 or inner cell mass cells are obtained andsubmitted to molecular genetic analysis as directed by orders in thepatient's database and dependent upon indications for the specificprocedure (for example, as shown in FIGS. 5,6).

A wide variety of analyses can be applied. For example, the molecularanalysis can include one or more of the following: in situ hybridizationto evaluate chromosomal structures, polymerase chain reaction directedto detect specific mutations or other defects gene organization, wholegenome hybridization, microarray gene chips, exome sequencing, oranalysis of the entire human genome as indicated (FIG. 6). Tests can beperformed in duplicate for confirmation, because 10-20 cells should beadequate. The biopsied embryos are frozen or vitrified in liquidnitrogen for preservation. Within 24 to 48 hours, the results can beplaced on the secure electronic network and reported to the subscribersand discussed with the patient and partner.

The status of each embryo and the results of the genetic analysis arereported by secure link in real time to each subscriber clinic throughits secure computer terminal 179,181 Internet 198 (FIG. 12). Thesubscriber clinic 178 will also contact the patient and her partner. Thesubscriber will select a strategy. Embryos identified as suitable forreplacement will be delivered cryopreserved to the subscriber's clinicfor replacement at a later time, weeks or months.

At an appointed time, the frozen blastocyst 132 selected for transfer(FIG. 7a ) is delivered to the subscriber's clinic by the nursepractitioner in a security-coded container 196 that is matched to theidentification of the patient and her partner using electronicidentification chips 196.

Identities of the patient and her partner are reconfirmed with facialrecognition and iris/retina scans. The embryo is thawed in thesubscriber's network protected facility 178, photographed, loaded into atransfer catheter under the supervision of the nurse practitioner, andthen transferred into the patient by the network nurse practitioner(FIGS. 7a, 7b , 12)

Resulting pregnancies are followed by the subscriber clinic 168 andprenatal care will take place in the clinical infrastructure of theregion.

Contractual arrangements with between the network system and corelaboratories and subscriber clinics and laboratories will include securespace and equipment allocated exclusively to network operations. Theglassware and all laboratory equipment involved with network will becolor-coded and inventoried for no other uses except network patientsand personnel specially employed or contracted by the network. Everystep involved in the flow and management of embryos will be markedelectronically and linked to the identity data of the patient and herpartner. Births, perinatal outcomes, and genetic evaluations will alsotake place in the local infrastructure and will be documented andarchived in the network database. Long-term follow-up of the births andprogress of the children into adulthood will be readily achievable usinginformation from the network database with confidentiality limits setwithin U.S. Government standards.

The network system will also negotiate and establish contracts withmedical insurance companies for provision of its services on a basic payfor performance scale centering on, for example, a $30,000 fee for aviable unaffected pregnancy.

We now describe catheters and subassemblies that have a broad range ofapplications both within and in addition to uses in the network systemand treatment of genetic disease. Details of the devices and componentsare described in text dealing with FIGS. 13-64 e.

Uterine lavage devices have both reusable and disposable (one-time-use)elements. An operating frame 8 and hard stands 198 (FIG. 13b ) used tostabilize them will be (significant) one time investments, for example,for clinics seeking to utilize the systems for other applications. Inthe case of uses for network system purposes, the network system willpay for and supply the frame and hard stands.

In some implementations, lavage fluid supply lines 20, suction cannulas16, recovery traps 28, insulated shipping containers 31 and tubing maybe (are likely to be) one time use disposables. Any two or more of themcan be sold as kits for use on the network operating frames. Theoperating frames 8 are typically non-disposable and after each procedureare sterilized and are placed in a kit for usage.

In some implementations, the lavage device may be kitted withsuperovulatory drugs and/or GnRH antagonists. Such kits may include butare not limited to a kit for uterine lavage comprising a uterine lavagecatheter configured for insertion into a woman's uterus to remove viableblastocysts; and one or more containers comprising a sufficient dosageamount of GnRH antagonist to cause desynchronization through corpusluteum apoptosis.

A kit for uterine lavage comprising a uterine lavage catheter configuredfor insertion into a woman's uterus to remove viable blastocysts fromthe uterus; one or more first containers comprising a sufficient dosageamount of FSH appropriate for induction of superovulation; one or moresecond containers comprising a sufficient dosage amount of a GnRHantagonist to silence the ovaries while causing superovulation; one ormore third containers comprising a GnRH antagonist to be administeredafter superovulation.

Both permanent (reusable) and disposable (one time use) elements andrelated support services will have commercial application and marketpotential outside of preimplantation genetics.

Examples of applications of intrauterine lavage and the devices that wehave described, outside of the network system could include thefollowing. 1) Embryo donation: Uterine lavage can be used as anonsurgical method for embryo donation that will compete with IVF. Theavailability of newer safeguards to protect donors from sexuallytransmitted viral diseases will allow uterine lavage to be used as asimpler and less expensive alternative. 2) Embryo banking: Uterinelavage will also be a useful technology allowing couples wishing todefer child bearing to cryopreserve and bank their own embryos for thebenefit of career ascension, for example. An additional use could bedeferred use in anticipation of technical advancements in geneticscreening and gene therapy for a condition or disease for which therewas no effective treatment at the time of the initial blastocystrecovery 3) Oncofertility: Uterine lavage may find application forpatients with malignancies who wish to cryopreserve and bank their ownembryos prior to cancer therapy. 4) Diagnosis of fertility and pregnancywastage disorders: Uterine lavage may be useful in embryonic diagnosisof various fertility and pregnancy wastage disorders by facilitatingrecovery and diagnostic manipulation of preimiplantation embryosconceived in vivo.

We overview general construction and clinical operation of examples of adevice useful for intrauterine lavage. The principles of construction,operation, and use represented by the examples described and shown herecan also be implemented in a wide variety of other examples.

In various configurations of the examples discussed here, the lavagedevices have three elements in common (FIGS. 13-16; 36-39): 1) anoperating frame 8, 2) a suction-recovery cannula 16, and 3) one or twofluid supply catheters 36,64,66 passed though individual guide channels34 extruded at manufacture into the inner walls of the suction-recoverycannula 16. In some implementations, each of these features, or two ormore of them in combination may be incorporated in a device or parts ofa device and a procedure or parts of a procedure without the otherfeatures. Each of the three features has significance of its own, asdescribed below and can be used itself in a wide variety of devices andprocedures.

In some examples of their use and operation, before the lavage, thethree components are pre assembled with dimensions and settings that, insome cases, have been predetermined and customized for each woman. Thesteps can include the following.

1) The operating frame 8, with the disposable components secured to it,is mounted on a rigid stand. The hard stand 198 is a heavy-duty versionof a common so-called Mayo table, which is readily available in thecommercial marketplace. Such a table can be slightly modified to supportthe weight of the operating frame. One person manages the lavage, withboth hands free to manipulate off and on functions of the externalcontroller and to make adjustments in the collection apparatus. Duringthe procedure, the patient is recumbent lying down and stabilized usingsoft restraints while the system is in operation. Two generic versionsof the operating frame (version #1 and version #2a/2b) are shown inFIGS. 13-16 and 36-39.

The operating frame stabilizes the systems for cervical and intrauterineinsertion of the suction-recovery cannula and its accessories and forsteering the fluid supply catheters and their tip(s) before, during, andafter lavage-recovery operations. The operating frames shown in FIGS.13-16 and 36-39 include an operating slide 25, which stabilizes, guides,and slides the various catheters, fittings, guides, tubing, andaccessories. The operating slide 25 is adjustable so as to limitinsertion depths.

It is important, during the lavage procedure, that the frame of theinstrument be held in a rigid position and orientation relative to thewoman's reproductive anatomy. The setting of the position andorientation can be aided by ultrasound and other techniques. Carefulpositioning and orientation helps to assure that the cannula lies at aneffective insertion distance within the woman and is properly seated bythe stops and with a good fluid-tight seal provided by the balloon.During catheter insertion, because the instrument is held in anessentially fixed position and orientation relative to the woman'sreproductive anatomy, the person performing the procedure can safely andeffectively deploy and remove the catheter(s).

2) The suction recovery cannula 16, 22 (sometimes referred to as 22 a or22 b) (FIGS. 13-17) includes a seamless conduit 22 that has a portionlying within a larger tube of the cannula 16 (discussed later) and aportion 22 that extends from the end of the larger tube for recovery ofembryos in lavage fluid and transfer of those embryos to a glassrecovery trap 28 mounted on the side of the operating frame 8. Thesuction recovery cannula 16, 22 embodies one suction recovery channel 23and two or three accessory channels (FIGS. 17-22) imbedded within thelarger tube of the cannula. One or two of these channels 34 are provided(depending on the implementation) to guide the deployment of one(version #1) or two (version #2a/3b) fluid supply catheters 36, 64, 66into the uterus. The larger tube of the cannula also includes aninsufflation channel 18 (occupying, for example, 2 to 8% of thecross-sectional area of the larger tube) delivers sterile fluid or airto an inflatable collar-funnel 12 at the tip of the suction cannula.(FIGS. 21, 22, 45, 46)

The suction cannula 16, 22 is tipped with an intracervical rubberinflatable collar 12 (FIG. 17, for example) which, when inflated 46immediately after insertion with 1-3 ml of air or fluid, serves both asa watertight seal (of its outer wall) against the internal os 155 (toprevent fluid from leaking out of the uterus and into the cervix duringthe procedure, and also as a funnel-shaped intake port (defined by itsinner wall) for collection and recovery of lavage fluid (FIGS. 16,31-33, 35, 60, 61). After insertion of the cannula through the cervixand into the uterus, the rubber inflatable collar 46 is placed in aposition immediately above the internal os 155 where it preventscompletely the loss of lavage fluid around the suction-recovery cannulaand outward through the cervix into the vagina. The proximal end of thesuction line 22 is connected to a recovery trap 28 a mounted on the leftside of the operating frame 8 (FIGS. 13-16, 36-39). The trap 28 isconnected to the pulse pump suction by a vacuum line 24. The trap isremoved at the end of the procedure and the fluid it contains is scannedfor embryos.

3) Fluid supply catheters, comprising one 20 (Version #1) or two 64, 66(Version #2a/2b) lines, are pre-inserted into their guide channels 34manufactured into the suction cannula 16, 22 a, 22 b prior to thearrival of the patient. The sizes and shapes of the catheters (which aredisposable items) are selected to fit the patient and achieve effectivelavage. They are connected to an external controller 205 (FIG. 13c )programmed to both deliver lavage liquid to the uterus and apply vacuumto the fluid supply catheters, which supplies uterine lavage fluid in apulsed rhythm. The controller pump 232 is connected to the cathetersupply line 20. A vacuum element alternates suction in pulses cadencedexactly the opposite as pulses used for fluid delivery (that is, when apulse is applied, the suction is off, and vice versa correct). Suctionpulses are managed via means of a pinch valve 231. Lavage fluid issupplied to the pump from an external reservoir through the intake portof the pump. For example, the pulsing can be done at a preset frequencyin the range of one pulse per 0.5 to 4 seconds. The pulse rate isdetermined empirically in clinical trials to achieve the most effectiveand efficient flushing of the uterus to produce the maximum embryoyield. The pulse rate is programmed into the controller 205.

Uterine lavage (FIGS. 3, 4) is typically performed between 5 and 8 daysafter the LH dose or LH surrogate trigger that released in vivo themultiple oocytes resulting from the superovulation. At the optimal time(most likely day 5), blastocysts 88 are present suspended in uterinefluid in the potential space 126 between the anterior and posterioruterine walls at approximately the geometric center of the uterinecavity. This location is in close proximity to the ultimate site ofimplantation, which is believed would take place within one day or lessafter the procedure were there blastocysts remaining in the uterusafterward.

Preparatory to lavage, prior to superovulation and insemination, apractice lavage can be performed (approximately one or two months)before the live procedure is scheduled. In the practice lavage, theinstruments are custom fitted, the guides, balloons, and other devicesare attached into place on the operating frame 8 and measurements aretaken (with the assistance of imaging technologies) that will enable theanatomy of each patient to be accommodated. Precise imaging of eachwoman's anatomy utilizes imaging devices, e.g., two-dimensional orthree-dimensional ultrasound, magnetic resonance imaging, or otherimaging technology. In one example, the length of fluid supply lines 64,66 required to form a complete loop with the confines of the uterinecavity must be determined and recorded. In a second example the anglebetween the cervical stop 14 and the distal suction line 16 needs to beknown in order to facilitate simple and comfortable insertion of thesupply lines 64, 66. In a third example, the degree of cervicaldilatation needs to be known and fitted into the instrument to be usedon that patient.

On the day of the lavage procedure, prior to the arrival and positioningof the patient, a previously assembled catheter-operating frame 8 andsupporting lavage instrumentation is assembled and set up in thetreatment room adjacent to a gynecological examination table. Prior tothe patient encounter, instruments are pre assembled from disposable andreusable elements, and adjusted as determined by the uniquecharacteristics of each woman as previously determined and measured atthe time of the trial lavage. Thus disposable fluid supply catheters 20,64, 66 of the right size and configuration are preloaded into theirrespective channels initially fabricated in the suction-recovery cannula16 at manufacture. The operating frame 8 and associated instruments arefirmly secured on a fixed floor mounted hard stand 198 placed at thefoot of the gynecological examination table. The pulsing and suctionelements are connected so that the instrument is ready for theprocedure.

In summary, in preparation for the live lavage, the disposable andreusable elements of the instrument are selected based on priormeasurements and study of the woman's anatomy and assembled and attachedto the pulsing and suction elements, ready for the procedure. In thisway, the live lavage is expected to produce the most efficient andeffective recovery of embryos possible.

In a live lavage (live in the sense that embryos are present), theprocedure begins with the patient on her back in a dorsal lithotomyposition. After insertion of a sterile vaginal speculum (not shown), theinner walls of the vagina 92 and the cervix 90 are cleansed with steriletissue culture fluid. The bladder is left distended so that theprocedure can be monitored in real-time by abdominal ultrasound. Twohours before the procedure, if needed for a woman with a stricturedcervix 90, the endocervical canal 157, as described previously isdilated with a sterile laminaria (“dry seaweed”) expander. To begin theprocedure, the endocervical canal is then mechanically dilated, ifnecessary, to accommodate a #15 to #34 French device.

Lavage-embryo recovery operations are now performed in four steps: 1)Intracervical insertion of the suction-recovery cannula into the cervix;2) Insufflation of the funnel balloon; 3) Intrauterine insertion,steerage and placement of fluid supply catheter(s) and lavage; and 4)Embryo recovery as follows.

1) Intracervical insertion: The procedure begins when the suctionrecovery cannula tipped by its endocervical guide is directed throughthe vagina into through the endocervical canal (FIG. 3). As the cannulais inserted, a cervical stop 14 flange on the distal end of thesuction-recovery cannula comes to rest against the exocervix 90, 170 andlimits the insertion depth of the guide. The system is now in place fordeployment of lavage fluid supply catheters 20, 64, 66.

2) Insufflation: With the suction cannula endocervical guide 16, 22 a,22 b inserted to its predetermined depth and its cervical stop 14 flangepushed firmly against the cervix at the internal os, the funnel balloonis insufflated with 1-3 cc of air or fluid (e.g., sterile water). Fullinsufflation of the funnel balloon 12, 46 seals off the endocervicalcanal and prevents any transcervical loss of lavage fluid and embryos.

3) Intrauterine insertion, steerage, and placement of fluid supplycatheters, and lavage: With the funnel balloon 12, 44, 46 fully inflatedand sealing the cervix, the fluid supply catheters 20, 64, 66 are thenguided into the uterine cavity 126 using wheeled steering controls 26,26a, 26 b and linkages mounted on the operating frame and customized toversion #1 or version #2a or #2b. The instruments are connected to thecontroller delivery pump 232. The pump is energized and a total of, forexample, from 10 to 100 ml of pulsating lavage fluid is infused throughthe system and uterine cavity and recovered over a period of, forexample, 30 seconds to 5 minutes. The volume of fluid within the uterusis not to exceed 10 mL at any given time so as to not over pressurizethe cavity or cause contractions, which would be painful to the patientand affect the recovery efficiency of the procedure.

Operations using version #1 and version #2a/2b are different and aredescribed individually.

With Version #1, a (#10 to 16 French in various examples) (FIGS. 13-16)single lumen supply line catheter 20 constructed of medical gradebiochemically inert medical grade composite (for example Teflon®) isused. It is tipped with a hollow steel ball 10 fabricated from veryhigh-grade grade steel or composite machined in nanotechnology. In someimplementations, the steel ball tip 10 contains two internally taperedports 38 that direct lavage fluid downward in two distinctly formed andoppositely aimed streams that contact, break up, flush, and force mucousand cellular debris from the uterus into the wide, funnel-shaped suctionport 43 which is located at the bottom of the uterine cavity in the baseof the funnel balloon and is connected to the suction cannula and itssuction recovery channel 23.

The two ports 38 in the steel ball tip are considerably larger thanother ports 40 (FIG. 26) of the catheter and are internally tapered todeliver higher pressure, higher flow, and highly focused stream relativeto the tapered ports. The configurations of the ports 40 are customizedindividually in accordance with the uterine anatomy of a particularpatient, determined at trial lavage. The angle between the directions ofthe two streams will range from 90-degrees to 150-degrees from the axisof the catheter as required to direct the fluid stream away andinferiorly from both internal ostium 104, 106 structures (FIGS. 35e, 35f). After the angle is determined, catheters are supplied and customizedfor that one patient based on earlier measurements. The catheters aredisposable. The fluid supply catheter 20 is keyed by an internal groovestop lock machine into its channel 34 and cannot be internally rotatedinside the uterus. Therefore, the directions of flow of the two streamsrelative to the orientation of the walls of the uterus is fixed in theappropriate positions so that as the catheter is deployed the ports areproperly oriented and the two streams will flush through the uteruseffectively for embryo collection.

In some implementations, the catheter (and one or more of the otherdisposable elements) is custom fabricated by the manufacturer for eachpatient between the time of the test lavage and the time of the livelavage. In some implementations, the catheter or one or more of theother disposable elements of the instruments are supplied in a number ofdifferent sizes and configurations and can be assembled at the clinicwithout requiring custom manufacturing.

The customized fluid flows from the steel ball ports have directions,volumes, velocities and that functionally obstruct loss of lavage fluidinto the oviducts 100,102 (FIG. 35e, 35f by forming a hydraulic wallisolating the central uterine cavity from the internal ostia. In someimplementations, the supply line contains from 8 to 10 secondary (4 ormore on each side) low pressure ports that direct streams 102 of lavagefluid into the center of the uterine cavity 126 and downward into thefunnel and its suction port 43. The flow of the lower pressure streamsis restricted to the middle parts of the uterine cavity, are lessforceful and less directed than the flows from the steel ball ports. Thepurpose of the lower pressure streams is to provide a diffuse pool offluid that will solubilize the mucous matrix of the intrauterine fluidand facilitate a sweeping current containing all embryos in the uterusand facilitate their direction into the funnel and its suction port 43.Just as the orientations of the steel ball ports are fixed relative tothe orientations of the walls of the uterus, so are the rows of ports infor the secondary streams that are positioned along the external wallsof the catheters. This results in a controlled flow of fluid to achieveeffective and efficient recovery of embryos.

In some examples of Version #2a/2b, two supply catheters are insertedand then guided along the lateral most walls of the uterine cavity tonearly meet at the upper end of the uterus (FIGS. 52, 53) (Version 1a)or snap together by their magnetic tips (FIGS. 64a-d ) (Version 2b) atthe top of the uterine cavity (FIG. 64a-d ). The disposable supplycatheters 64, 66 are pre inserted into the two supply channel suctionrecovery cannula 16, 22 b into their own channels 34 with in the lateralinternal walls of the suction cannula before its insertion into theuterus. They are keyed into their channels 34, 64, 66 and can beinternally rotated inside the uterus yet restricted to rotation within a90-degree arc as limited by interlocking grooves machined into the wallssuction recovery 22 a, 22 b device in each of the respective supply linechannels.

After the suction cannula is securely in place and the funnel balloon isfully inflated 46, 48, 50, the two supply catheters 64, 66 are advancedinto the uterine cavity by manipulation from the respective controlwheels and linkages 26, 26 a, 26 b. As they are advanced, they cling toboth sidewalls of the uterus as directed by the shape memory of theirshape memory materials 94, 98. The catheters are snaked (manipulated)into position by a combination of upward and torque forces as shown inFIGS. 63a-m .) directed by twisting the torque wheels 26 a, 26 b withlinkages to the two channel slider block 119 a, 119 b and merger blocks84 a, 84 b mounted on the operating frame. During insertion, they aredirected away from and therefore pass by both internal ostia 104, 106and then meet at the top of the uterine cavity 126. Ultrasound imagingcan be used to aid the insertion process. In many cases, the operatorwill develop the ability to perform the insertion by “feel” without theneed for imaging.

Both catheters contain ports 72, similar to the ones in the previouslydescribed version, that direct a flow of lavage fluid directly to thecenter of the uterus to break up the uterine fluid film, dislodgeembryos, and direct them into the inflated funnel-balloon and itssuction port 43 located at the internal os 155 of the uterine cavity 126and held in place by funnel balloon 46 at the tip of the suctioncannula.

Outside the woman's body, the suction cannula then directs the lavagefluid flow and embryos into the recovery trap 28 a attached at the endof the vacuum line 24. The catheters are both keyed into their guides34, 65, 66 so that the ports always face the middle uterine cavity andcannot force fluid into the internal ostia. During the lavage procedure,no embryos are lost via the internal ostia because all flow is directedtoward the center of the endometrial cavity and then downward to theballoon funnel and suction port 43 at the internal os. Thus, there is noforce or flow that would cause the embryos to flow toward or through theinternal ostia into the Fallopian tubes where they would be lost. WithVersion 2a, the flow of fluid is stopped at the end of the procedure andthe catheters and supportive elements are removed. With Versions 2b, thetwo lines, when they meet at the top of the uterine cavity, engage bytheir magnetized tips and form a closed perimeter around the embryos.The lavage fluid continues to flow as the device is withdrawn. Theperimeter collapses around the embryos and continues to surround themand flush them from the uterus almost until the instrument is withdrawn(FIGS. 64a-64e ). The collapsing perimeter is further assurance that noembryos are lost. In other words, the streams emanating from thecatheters that form a looped perimeter continue to wash the embryos fromthe uterus towards the funnel in a sweeping action as the catheters arewithdrawn and the perimeter closes in on the funnel.

We sometimes use other broad terms to refer to the flow of the fluidwithin the uterus from the delivery of the fluid to the collection ofthe fluid. For example, the multiple streams emanating from the cathetercan form what is called a layer of fluid, or a curtain of fluid or awash of fluid. We use all of these terms in a broad sense.

4) Embryo Recovery: Lavage fluid containing embryos is delivered underintermittent suction into the suction cannula port 43 located at thebase of the inflated funnel balloon 46 which occludes the cervix.Embryos in the fluid then flow through the seamless suction channel andtubing to the embryo recovery trap 28 a snapped on to the side of theoperating frame. At the end of the lavage procedure, the recovery trap28 a containing the lavage fluid is marked using electronicidentification tags 184 (FIG. 13 13 b and removed from the operatingframe. The trap then is filled to a full mark with sterile transportmedia and sealed 28 b with a glass stopper for transport to the coreembryology genetics laboratory facility 174. The transport flask 28 b iscontained inside an insulated transfer block 31 and transported in aninsulated carrying case

The instruments are removed and the patient is discharged. The procedurefrom insertion of the suction cannula to embryo recovery in the trap isexpected to take 15 minutes. The disposable portions of the instrumentare discarded as medical waste, and the reusable portions are sterilizedfor reuse.

We now describe details of construction and mechanical operation ofindividual device components and illustrate them in FIGS. 13-64 e.

FIG. 13 shows an example of the Version #1 operating frame andcomponents in its undeployed configuration. It is a left side view ofthe completely assembled single catheter lavage instrument 8 inreadiness mode (prior to uterine insertion). The operating frame 8 is arigid platform for mounting and securing working elements of the system.The complete system, when mounted on the operating frame 8 platforms, issecured to an adjustable, movable, but rigid stand placed on the floorat the foot of the gynecological procedure table. The instrument iscomprised of three elements on the operating frame: the operating frame8, the suction recovery cannula 16, 22. As mentioned earlier, portion 22of the suction recovery cannula is a tube that carries the embryos influid to the recovery container 28 a; portion 22 extends into a largerdiameter tube that is also part of the cannula and that we sometimesrefer to as the large tube 16. Tube 16 also carries other elements ofthe instrument. Sometimes we refer to the cannula as cannula 16, 22.),and one fluid supply line 36 which is passed through an individual guidechannel extruded at manufacture into the inner walls of the large tubeof the suction recovery line 16, 22 at manufacture.

The fluid supply line 20 is attached to an external controllerprogrammed to delivery lavage liquid to the uterus in pre-programmedperiodic pulses. The operating frame platform 8, mounted on a hard stand198 stabilizes the systems for cervical and intrauterine insertion ofthe suction recovery catheter 16, 22 and its steering control 26 fordirecting the fluid supply catheter 20 and its steel oval tip 10 before,during and after lavage recovery operations.

The operating frame 8 includes the operating slide 25 which stabilized,guides and slides the mechanically linked catheters, fittings, guides,tubing as they are directed into the uterus. The operating slide 25,calibrated in centimeters, is custom set before each procedure for eachpatient and limits uterine insertion depth of the suction line at itsflanged tip 14 surrounded by a balloon collar 12.

The vacuum line or port 24 is built into the base of the operating frame8 and links directly to the vacuum pump 233 (FIG. 13c ). The pump iscontrolled to apply an intermittent vacuum (syncopated to the pulsationsof uterine lavage fluid that is being infused into the uterus) to thetubing and is connected to the embryo recovery trap 28 a which collectsall of the lavage fluid which contains all of the embryos. Vacuumpressure in the fluid delivery and collection device is managed via apinch valve 231. The vacuum delivered in the embryo recovery trap istransmitted into the suction recovery cannula 22, which in turn istransmitted to the uterine cavity during lavage intrauterine infusioninvolved with embryo recovery. The trap 28 a is removed at the end ofthe procedures and fluid recovered is transported in an insulatedtransport block 31 to the central embryo laboratory where it is scannedfor embryos.

The suction recovery line 16, 22 is a seamless conduit for recovery oflavage fluid and embryos. The suction recovery line 16, 22 transportsembryos seamlessly to the suction trap 28, which is mounted on the leftside of the operating frame 8. The suction recovery line is manufacturedby extrusion as a semi-rigid medical grade inert composite. The suctionrecovery line (FIGS. 18-25) 22 has a central suction recovery channel 23(ranging from, 30-80% of its cross-sectional area in various versions)with two accessory channels, one channel for the fluid supply line 34and the other for the balloon air supply 18, embedded into its walls atmanufacture.

The embryo recovery trap 28 is connected to the vacuum pump through aperforated rubber stopper by a vacuum line. The outside diameter of thesuction recovery cannula 22 a ranges from 22-34 French according todesign model and custom patient requirements.

At the beginning of the lavage procedure, the suction recovery cannula22 a is deployed through the cervix and into the uterus where itfacilitates insertion and instrumentation of the uterus. A cervical stop14 flange on the distal end of the suction recovery cannula 22 a, restsagainst the external cervix and limits the depth of insertion of thesuction recovery cannula 22 a into the cervix. Custom adjustmentsranging from 1.0 to 2.5 cm into the endocervix fix the depth anddirection of the angled distal portion of the guide.

A cervical stop scale 74 is etched into the outside of the suction linearm 16 and marks the position of the cervical stop when it iscustom-adjusted to each patient prior to insertion. The angle of thedistal portion of the suction recovery line 22 a is preset and variesfrom 0-45 degrees and is customized to individual women in order toaccommodate the different anatomical variations of the uterine flexion.

The distal most portion of the suction recovery line 22 a covers andshields the steel ball tip of the higher-pressure fluid supply line 20.The steel ball tip contains high precision double tapered ports fordelivery of fluid under higher pressure relative to the tapered ports.The distal most portion of the suction recovery cannula endocervicalguide 16 20, covers and shields the steel ball tip 10 of the fluidsupply catheter (s) during insertion, maintains sterility, and avoidsplugging of the higher pressured fluid supply catheter 20 with mucous.

The suction recovery catheter 16, 22 a is tipped with an intracervicalrubber inflatable collar 44, 46, 48, which when inflated immediatelyafter insertion with 1-3 ml of air or fluid, serves as a watertight sealand funnel shaped intake port for recovery of lavage fluid. Itsplacement is immediately above the internal os of the lower uterus whereit prevents completely the loss of lavage fluid around the suctionrecovery cannula 22 and 16 and outwards through the cervix into thevagina. It is connected to a controller programmed to both deliverlavage liquid to the uterus and apply vacuum in a pulse that alternatessuction and pulses cadenced exactly the opposite fluid delivery at apreset frequency of, for example, 0.5 to 4.0 seconds.

The balloon collar is inflated using air or fluid delivered by an airsupply syringe 116 connected to a channel extruded into the manufactureof the suction recovery line 22. The fluid or air is delivered through aballoon port 42.

The suction recovery line is connected seamlessly through a resin mergerblock 84 which links the recovery line 16, 22 seamlessly with theproximal line which delivers fluid into suction trap. The resin slideblock 118, 120 is linked directly to a steering control wheel 26 whichis manipulated by the hand of the operator and moves the supply line 20back and forth into the supply line guide channel 34

The operating frame 8 is secured through an attachment hard point 199 toa rigid hard stand 198 fixed to the floor of the treatment room througha rigid handle 76 that contains and secures the suction line 24 port andchannel.

A resin merger block 84 integrates the fluid supply line 20, suctionline 16, 22, and balloon air supply line 18 into a seamless merger. Theresin merger block is fixed to the main frame and does not slide. Theslider block 118 moves with the operating slide 25 and can be lockedinto a fixed position by a slider block 120. The excursion of theoperating slide is fixed proximally and distally, is adjustedindividually for each individual patient, and is locked into position byits slider block 120.

FIG. 14 shows an example of the Version #1 operating frame in its fullydeployed configuration. It is a left side view of the completelyassembled Version #1 uterine catheter instrument mounted on itsoperating frame 8 with its catheter mechanisms in fully deployedposition (inserted fully into the uterus). The operating slide andcontrol wheel are forward at maximum travel with the resin slider block118 and the resin merger block 84 in full contact. The distal supplyline 20 is fully extended with its steel ball tip 10 at maximumexcursion where it would contact the top of the uterine cavity ifactually inserted.

Uterine lavage fluid is delivered into the uterus at a low flow of fluidsupply that does not exceed a maximum pressure of the device betweenabout 2 PSI to 50 PSI through two tapered ports 38 machined into thesteel ball tip 10 and twelve tapered ports machined into the middle anddistal segments of lavage fluid supply line 20. Lavage fluid will bedelivered in short low pressure pulses through the steel ball tipbetween 0.5 mL/s to 20 mL/s, e.g. 1 mL/s to 10 mL/s, e.g. 1 mL/s to 5mL/s, e.g. about 1 mL/s with highly focused stream of fluid directed tothe uterine cavity wall at a point below the internal ostia 126 so as toform a functional hydraulic wall through which the embryos cannot moveretrograde from the middle uterine cavity into the respective right andleft internal tubal ostia.

In this figure, the balloon collar 12 is uninflated. The cervical stop14 will be pushed firmly against the cervix adjusted for the internallength of the endocervical canal. The balloon collar 12 is then fullyinflated and is pulled taut over the endocervix determined by thesetting of the cervical stop 14 to form a water tight funnel to theoutside of the uterus to assure no losses of uterine lavage fluid.

FIG. 15 is a top view of an example of the Version #1 operating frameand the uterine catheter instrument in its undeployed configuration. Thedistal suction line 16 port protects the distal steel ball tip 10. Theuterine supply line 20 is linked to the controller fluid delivery pump232. The steering control wheel 26, resin merger block and resin sliderblock are in their extended, undeployed position.

FIG. 16 is a top view of an example of the Version #1 operating frame 8and the uterine catheter instrument in its fully deployed configuration.The resin slider block 118 is fully extended to the distal travel of theoperating slide 25 and is pushed against the resin merger block 84 a.The steel ball nozzle tip is fit to the uterine cavity exposing thetapered ports 40 to delivering lavage fluid into the central part of theuterus from the fluid supply line 20. The balloon collar 12 is notinflated. Cervical stop 14 is fixed by pre-measuring of the patientaccording the scale attached to suction line 16 and 22 a.

FIG. 17 is a left side view of the Version #1 suction recovery line 22 aand resin merger block 84 a showing seamless integration of the suctionrecovery channel 23 and line 22, fluid supply line channel 34, andballoon air supply line 18 which are extruded into the catheter atmanufacture. The fluid supply line 20 is not shown in this figure.

FIG. 18 is an enlarged ¾ view of the Version #1 resin merger block 118.The suction line 22 a is connected seamlessly to the suction lineextruded into 16 the suction arm 16 at manufacture. A single supply linechannel 34 is supplied for insertion of the supply line 20, which is notin the figure. The balloon collar air line 18 runs in the wall extrudedsuction line arm 16 its full length to open in its port 42 inside theballoon collar at the tip of the catheter.

FIG. 19 shows the Version #1 merger block with the fluid supply line 20now in place to its own port 34. The supply line 36 is attached rigidlyto the resin slider block 118, which is linked to the steering control26 and the operating slide 25 (FIGS. 15, 16).

FIG. 20 is a left longitudinal cutaway of the Version #1 distal suctionline with the fluid supply line in undeployed mode. Tapered low flowports 40 (six on each side) are spaced at fixed intervals to deliverlavage fluid directly into the middle part of the uterine cavity duringlavage and break up the mucous content of the middle part of the uteruswhere embryos are located. The steel ball tip contains two highlymachined tapered ports 38 delivering lavage fluid under higher pressurerelative to the tapered ports directly just below the internal ostiaagainst the uterine wall. This figure is an undeployed configuration.

FIG. 21 is a left oblique cross section of the Version #1 distal suctionline 16 showing the extruded configuration of the suction channel 23.Extruded seamlessly into the wall of the suction recovery line 16 is thechannel for the lavage fluid supply line 34, the supply line 20, and theair line for the balloon collar 18

FIG. 22 is a cross section view of the Version #1 distal suction line 16showing the configurations of the suction channel 23, the lavage fluidsupply channel 34, the lavage fluid supply line 20, the balloon collarair line 18, and the arm of the suction catheter 22.

FIG. 23 is a left side view of the Version #1 distal suction line 16showing the cervical stop 14, the etched centimeter scale to eachpatient 74, and the distal arm of the suction line 16.

FIG. 24 is a left oblique cross section of the Version #1 distal suctionline 16 showing the cervical stop 14, the cervical stop scale 74, thesuction line 22, with suction channel 23, the balloon air supply line18, and the fluid supply line guide channel 34.

FIG. 25 is a cross section of the Version #1 distal suction line 16showing the cervical stop 14, the suction channel 23, and the supplyline channel 34. This distal cut is taken just distal to the cervicalcollar 14.

FIG. 26 is a left side view of the Version #1 fluid supply cathetershowing the resin slider block 118 which is fixed to the operating slide25, the tapered fluid delivery ports 40 delivering fluid to the middleof the uterine cavity, and the steel ball tip 10 with the tapering lowpressure fluid delivery ports 38.

FIG. 27 is the Version #1 resin slider block 118 that fixes the fluidsupply line 20 with notches that secure it to the operating slide 25.

FIG. 28 is an enlarged left sided view of the Version #1 distal fluidsupply line with the 8 tapered ports 40, steel ball tip 10, and taperedports 38.

FIG. 29 is an enlarged right sided view of the Version #1 distal fluidsupply line with the 8 tapered ports 40, steel ball tip 10, and taperedports 38.

FIG. 30 is an enlarged view of the Version #1 steel ball tip 10 showingthe tapered delivery ports 40 seamlessly attached to the distal fluidsupply line 20 with one example of the 8 tapered ports designed for lowpressure fluid delivery to the middle uterine cavity 126.

FIG. 31 is a half cutaway of the Version #1 steel ball tip showing thetapered ports machined into the steel ball 10 and the tapered ports 40designed for low pressure delivery at the middle part of the supply lineintended for delivery into the middle uterine cavity 126.

FIG. 32 left is the uninflated Version #1 balloon collar 12, the steelball tip 10 which is undeployed and covered, and the port 42 for airdelivery to the balloon 12.

FIG. 33 right shows a balloon collar 12 deployed but free standing andnot in the uterus so it is not deformed into a funnel.

FIGS. 34a and 34b show the Version #1 balloon collar 12 deployed as itwould be in the uterus at the internal os and lower uterine cavity 126.The steel ball tip 10 is undeployed. The tension of the cervical stop 14causes the balloon 12 to deform into the shape of the lower uterinesegment producing a water-tight seal so that lavage fluid cannot escape.When the balloon is deformed downward, it forms a watertight funnel 48,50.

FIGS. 35a-f illustrate Version 1 catheter placement and lavage fluidflow as it would be deployed in the uterine cavity.

In Version #1, a single supply line ending in a steel ball tip 10 withinternally tapered ports 38, directs flow of lavage fluid from the steelball tip 10 into the lateral uterine cavity 126 just below both internaltubal ostia 104 106 as well a fluid into the middle uterine cavity 126from ports directly into uterine fluid surrounding the embryos 72 102.

As illustrated in FIGS. 35e and 35f , the fluid flow is then deflectedfrom the lateral uterine wall into the fluid containing the embryos inmiddle uterus where it further dislodges them and directs them into theport of the suction line at the base of the funnel balloon. The steelball tip produces a higher-pressure highly focused flow of lavage fluidrelative to the tapered ports, which forms a hydraulic wall thatfunctionally obstructs the internal ostia 104,106.

FIGS. 35a and 35b depicts the uterus at time of insertion of the Version#1 tip. In FIGS. 35a through 35d , the steel ball tip 10 and singlesupply line 22 are passed through the intrauterine fluid surrounding theembryos 102 in mid uterine cavity 126 just above the catheter tip. Theballoon 44 is shown in FIG. 35a in a collapsed position; it will befilled with air or fluid which is insufflated through the balloon port42. The cervical stop collar 14 is preset to allow introduction of thecatheter tip to a precise pre-established depth. In FIG. 35a , theentire apparatus is passed through the vagina 92 to its position in thecervical canal protruding slightly into the cavity 106.

In FIG. 35b , the balloon collar 44 has been inflated 46 and isthereafter deformed into a funnel shape held tightly in the loweruterine cavity 126 by tension maintained by the cervical collar 14 atthe external cervix. The tightly held funnel balloon collar 46 forms awatertight seal such that no lavage fluid loss can be lost through thecervical canal 90, 157,

In FIG. 35c the steel ball tip 10 is introduced into the middle uterinecavity 98, 126 and passes through the embryos 88 on its way to the topof the uterine cavity 126 The deployment of the steel ball 10 is guidedby to the steering control wheel 26 which can be used in a proximal anddistal motion directed by the operating slide 25 where it is linkedthrough the resin keyblock 120.

In FIG. 35d , the steel ball tip 10 is steered through the embryonicimplantation sites 88 toward the top of the uterine cavity 80, 126. Theembryos 88 are floating in uterine fluid 161 and would not be expectedto be significantly dislodged by the passage of the supply line 20 andsteel ball tip 10.

In FIG. 35e the steel ball tip 10 has been passed to the top of theuterine cavity and fundus 80. Fluid is delivered under low pulsepressure to the supply line 22 through tapered ports 38 in the ovalsteel tip 10. The steel ball tip 10 contains two internally taperedports 38 delivering higher pressure and higher flow relative to thetapered ports, and highly focused fluid streams in directions thatdiffer by, for example, 90-150 degrees and pointed immediately belowboth internal ostia 104 106. Their highly focused streams forms ahydraulic wall that functionally obstruct the internal ostia 104 106 sothat no fluid escapes through the oviducts 86 104 106.

This angle of flow is customized to the unique anatomy of eachindividual patient as determined by pre-treatment ultrasound imaging.There should be no fluid escaping through the internal ostia to theoviduct 104 and 106. Under the same pulsatile pressure, lavage fluid isdirected simultaneously through rows of proximal ports of the supplyline 102 into the mid-segment in of the uterine cavity 126.Coincidentally suction is applied to the suction line 16 to the balloonfunnel 46 to allow flow of the lavage fluid out the suction line 16 withno losses around the initiated by the funnel balloon 36. Intermittentpulsatile flow through the steel ball tip 10 and through the taperedcatheter ports 38 allows for orderly breakup of uterine fluid containingembryos through the funnel in the suction line 16 to the embryo recoverytrap 28. By the combination of direct low pressure stream-forcingembryos away from the internal ostia 104 and 106 combined with thefunnel balloon 46 there should be no lavage fluid or embryonic losses.Thus this arrangement and other features of the instruments andprocedure are designed to achieve the ideal goal of removing all of theembryos present in the uterus through the suction line, to leave none ofthem in the uterus, and to force none of them into the ostia.

In FIG. 35f , the blastocysts are delivered into the balloon funnel andthe suction cannula port for transport through the suction catheter 16and embryo trap 28. At the termination of the lavage procedure, theentire apparatus is removed from the patient and the procedure isterminated. The fluid collected in the embryo trap 28 is taken to thecentral laboratory for recovery and genetic processing of the embryos.

FIG. 36 is the Version 2a/2b operating frame in its undeployedconfiguration. It is a left side view of the completely assembledVersion #2a/2b uterine catheter instrument mounted on its operatingframe 8 in readiness mode (prior to uterine insertion). The operatingframe 8 is a rigid platform for mounting and securing working elementsof the system. The complete system, when mounted on the operating frame8 platforms, is secured to an adjustable, movable, but rigid standplaced on the floor at the foot of the gynecological procedure table.The instrument is comprised of three elements on the operating frame:the operating frame 8, the suction recovery cannula 22 b, and two fluidsupply lines 64, 66 which are passed through individual guide channelsextruded at manufacture into the inner walls of the suction recoveryline 22 b at manufacture. The fluid supply lines 64, 66 are attached toa controller programmed to both deliver lavage liquid to the uterus andapply vacuum to the fluid delivery and collection device inpre-programmed periodic pulses. The operating frame platform 8stabilizes the systems for cervical and intrauterine insertion of thesuction recovery catheter 22 b and its steering controls 26 a,26 b fordirecting the fluid supply catheters 64 66 without or with magnetizedtips 68 70 before, during, and after lavage recovery operations.

The operating frame 8 includes the two operating slides 25 a 25 b whichstabilize, guide and slide individually the mechanically linked rightand left fluid supply catheters 64,66, fittings, guides, tubing as theyare directed into the uterus. The operating slide 25 a 25 b, calibratedin centimeters, are custom set before each procedure for each patientand limit uterine insertion depth of the supply lines 25 a 25 b. Atinsertion of the catheter, supply lines 25 a 25 b are stored at theflanged tip of the suction line 16 surrounded by a balloon collar 12.

The vacuum line external access port 24 is built into the base of theoperating frame 8 hereafter it links directly to the vacuum element 233of the programmable controller 205 and alternates vacuum to thepulsations of uterine lavage fluid that is being infused into theuterus. Suction tubing from the external access port 24 is connected tothe embryo recovery trap 28 which collects lavage fluid containingrecovered embryos. The vacuum delivered through the embryo recovery trap28 a is transmitted into the distal suction line 16, which in turn istransmitted to the uterine cavity during intrauterine lavage and embryorecovery. The embryo recovery trap 28 a is removed at the end of theprocedure where fluid recovered is transported to the core embryolaboratory 174 and scanned for embryos.

The suction line 16, 22 b is a seamless conduit for recovery of lavagefluid and embryos. The suction recovery line 16, 22 b transports embryosseamlessly to the suction trap 28, which is mounted on the left side ofthe operating frame 8. The suction recovery line 16, 22 b ismanufactured by extrusion as a semi-rigid medical grade inert composite.The suction recovery line 16, 22 b has a central suction recoverychannel 23 (ranging 30-80% of its area in different modifications) withthree accessory channels, two channels for the two fluid supply lines 34and the other for the balloon air supply 18, embedded into the walls ofthe suction catheter at manufacture. The embryo recovery trap 28 isconnected to the controller vacuum element not shown through aperforated rubber stopper 29 by a vacuum line. The outside diameter ofthe suction recovery cannula 16 ranges from 22-34 French according todesign model and custom patient requirements. At the beginning of thelavage procedure, the suction recovery cannula 16 is deployed throughthe cervix and into the uterus where it facilitates insertion andinstrumentation of the uterus. A cervical stop 14 flange on the distalend of the suction recovery cannula 16, rests against the externalcervix and limits the depth of insertion of the suction recovery cannula16 into the cervix. Custom adjustments ranging from 1.0 to 2.5 cm intothe endocervix fixate the depth and direction of the angulated distalportion of the guide. A cervical stop scale 74 is etched into theoutside of the suction line arm 16 and marks the position of thecervical stop when it is custom-adjusted to each patient prior toinsertion. The angle of the distal portion of the suction recovery line16 is preset and varies from 0-45 degrees and is customized toindividual women in order to accommodate the different anatomicalvariations of uterine flexion. The distal most portion of the suctionrecovery line 16 covers and shields the tips of the fluid supply lines64, 66. The distal most portion of the suction recovery cannulaendocervical guide 16, covers and shields the tips of 52 of the fluidsupply catheters 64, 66 during insertion, maintains sterility, andavoids plugging of the fluid supply catheters 52, 64, 66 with uterinefluid 16 and debris.

The suction recovery catheter 16 is tipped with an intracervical rubberinflatable collar 44, 46 and 48, which when inflated immediately afterinsertion with 1-3 ml of air or fluid, serves as a watertight seal andfunnel shaped intake port for recovery of lavage fluid. The balloon 46placement is immediately above the internal os 155 of the lower uterinecavity 126 where it prevents completely the loss of lavage fluid aroundthe suction recovery catheter 27 and outwards through the cervix intothe vagina. It is connected with an external controller (not shown),which supplies uterine lavage fluid in a pulse rhythm to a vacuumelement that alternates suction and pulses cadenced exactly the oppositeof fluid delivery at a preset frequency of 0.5 to 4.0 seconds.

The balloon collar 12 is inflated with air or fluid delivered by an airsupply syringe 116 connected to a channel extruded at manufacture intothe walls of the suction recovery line 16. The fluid or air is deliveredthrough a balloon port 42.

The suction recovery line 16 is connected seamlessly through a resinmerger block 84 b which links the proximal and distal suction recoverylines 16 22 b seamlessly to deliver fluid into the embryo recoverysuction trap 28. Two resin slider blocks 119 a 119 b are linked directlyto right and left steering control wheels 26 a 26 b which are movedproximally or distally or rotated through 180 degree clockwise orcounter clockwise arcs by the hand of the operator. The right and leftsteering controls manipulate supply lines 64,66 proximally and distallyin their respective supply line guide channels 27 b or rotate themthrough 180 arcs keyed to their respective resin slider blocks 119 a 119b.

The operating frame 8 is secured through a hard point 199 to a rigidhard stand 198 fixed to the floor of the treatment room through a rigidhandle 76 that contains and secures the suction line port 24 andchannel.

A resin merger block 84 b integrates the fluid supply lines, suctionlines, 64 66 and the balloon air supply line 18 into a seamless merger.The resin merger block 84 b is fixed to the main frame and does notslide. The slider blocks 119 a 119 b move with the operating slide 25 a,25 b and can be locked into fixed position by a slider lock 120. Theexcursion of the operating slide is fixed proximally and distally, isadjusted individually for each individual patient, and is locked intoposition by its slider block 119 a 119 b.

FIG. 37 is the Version 2a/2b operating frame in its fully deployedconfiguration. This is a left side view of the completely assembledVersion #2a/2b uterine catheter instrument mounted on its operatingframe 8 with its catheter mechanisms in fully deployed position(inserted fully into the uterus). The right and left operating slides 25a 25 b and right and left steering controls 26 a, 26 b are forward atmaximum travel with the resin slider block 118 the resin merger block 84a in full contact. The right and left distal supply lines 64,66 arefully extended with or without magnetized tips 68 70 at maximumexcursion where they are steered along the top of the uterine cavity, ifactually inserted, where they make contact to form a mechanicalperimeter around the embryos located in the middle uterine cavity.Uterine lavage fluid is delivered in short low-pressure pulses throughports machined into both right and left supply lines and directeddirectly into the middle uterine cavity. In this figure, the ballooncollar 12 is uninflated. The cervical stop 14 will be pushed firmlyagainst the cervix adjusted for the internal length of the endocervicalcanal. The balloon collar 12 is then fully inflated and is pulled taughtover the endocervix determined by the setting of the cervical stop 14 toform a water tight funnel to the outside of the uterus to assure nolosses of uterine lavage fluid.

FIG. 38 is a top view of the Version #2 a/2b operating frame and theuterine catheter instrument in the undeployed configuration. The distalsuction line 16 ports protect the double tips of the two supply lines52. The two fluid supply lines 64, 66 are linked to the controller fluiddelivery pump 232, and the suction line 24 is linked to the controllervacuum pump 233. The right and left steering controls 26 a 26 b, resinmerger block 84 a, and resin slider blocks 118 a 118 b are fullyextended in their undeployed positions.

FIG. 39 are a top view of the Version #2 operating frame and uterinecatheter instrument in fully deployed configuration. The resin sliderblocks 118 a 118 b are fully extended to the distal travel of theoperating slide 25 a 25 b and are pushed against the resin merger block84 b. The two fluid supply lines are in fully extended position withoutrotation so they point away from each other. If deployed in the uterus,they would have met and attached at their magnetized tips at the top ofthe uterus to form a mechanical and hydraulic perimeter around theembryos located in the middle of the uterine cavity. The balloon collar12 is not inflated. Cervical stop 14 is fixed by pre-measuring of thepatient according the scale attached to suction line 16

FIG. 40 is a left side view of the Version #2/2b suction line 16 whichcontains channels for two fluid supply lines 64, 66. The suction line 27is a seamless conduit for recovering and transporting embryos containedin the lavage fluid for delivery to the embryo trap 28 by way of theresin merger block 84 b. This version accommodates two fluid supplylines 64,66 that emerge together in the resin merger block 84 a and canrotated 180 degrees by their mechanical linkage through right and leftresin slider blocks 118 a 118 b. Which in turn are mechanically linkedto the right and left steering controls 26 a 26 b.

FIG. 41 is an enlarged ¾ view of the Version #2 resin merger block 84 b.The suction line 16 is connected seamlessly to the suction line extrudedinto the suction arm 16 at manufacture. Two supply line channels 27 a 27b are supplied for insertion of the supply lines 64 66, which are not inthe figure. The balloon collar air line 18 runs in the wall of extrudedsuction line arm 16 its full length to open in its port 42 inside theballoon collar at the tip of the catheter.

FIG. 42 shows the Version #2 resin merger block 84 a with fluid supplylines 64,66 now in place to their own ports 27 a 27 b. The supply lines64, 66 are attached rigidly to their respective resin slider blocks 118a 118 b, which are linked to the steering controls 26 a and 26 b and theoperating slide 25. This arrangement allows for 180 degrees withinuterus rotation of both fluid supply lines from respective right andleft resin slider blocks, which are mounted on their respective rightand left operating slides.

FIG. 43 is a top side longitudinal cut of the Version #2 distal suctionline 16 showing both fluid supply catheters 64, 66 in place. Thecatheter tips 52 protrude slightly from the tip. The lavage fluid supplyports 72 can be seen through the cut. The cervical stop flange 14 isshown in cross section.

FIG. 44 is a left longitudinal cut of the Version #2 distal suction line16 shown from the left. On side view a right and left supply lines canbe seen with their respective fluid supply line ports 72 and tips 52protected by a distal suction line 16.

FIG. 45 is a left oblique view of the Version #2 cross section cutthrough the distal suction line 16 showing the suction channel 23 andballoon air channel 18, and two supply catheter channels 34 with fluidsupply lines 64, 66 in place.

FIG. 46 is a cross section of the Version #2 distal suction line 16showing the suction channel 27 b, balloon air channel 18 and two supplycatheter channels 27 b with fluid supply catheters 64, 66 in place.

FIG. 47 is a left sided view of the distal Version 2 suction line 27showing the cervical stop 14 in place with the centimeter graduatedetched preset scale 74.

FIG. 48 is a left oblique cross section of the Version #2 distal suctionline 27 showing the cervical stop 14, suction channel 27 a, balloon airchannel 18, and two fluid supply catheter channels 34

FIG. 49 is a cross section of the Version #2 distal suction line 16showing the cervical stop 14, suction channel 23, balloon air channel18, and two fluid supply catheter channels 34.

FIG. 50 is a right side view of the Version #2 left fluid supplycatheter 64 at the top and a left side view of the patient's right fluidsupply catheter 66 at the bottom. The catheters each contain nineinternally tapered fluid delivery ports 72 which, when deployed in theuterus, are pointed to the middle of the uterine cavity. Individualresin slider blocks 119 a 119 b are linked mechanically to the right andleft steering controls 26 a, 26 b, and lavage fluid delivery ports 64.

FIG. 51 is a left side view of the patient's right side Version #2 fluidsupply catheter 66 at the level of the resin slider block 119 b (119 anot shown) with mechanical attachment points to the operating frame 8and right and left steering controls 26 a 26 b.

FIG. 52 is an anterior posterior view of the deployed Version 2 doublesupply line system with fully inflated funnel balloon 12 that completelyoccludes the internal os 155. The right sided 64 and left sided 66 fluidsupply lines have been steered along respective right and left uterinewalls within the cavity to nearly meet at the top of the uterine cavity126. In this system all uterine lavage fluid is delivered away from theinternal ostia directly into the lower uterine cavity and then to thefunnel balloon 12 that occludes the endocervical canal. This systemutilizes intermittent pulsatile delivery of fluid and suction to breakup the uterine cavity fluid 161 and mucous and move the embryos to thefunnel balloon 12 in the lower uterine cavity 126.

FIG. 53 is an anterior posterior view showing the Version 2 method ofinsertion and rotation of the patient's left fluid supply line 64 intoand then away from the left internal ostium 104. This is achieved byrotation of the left steering control 26 b steering the tip away fromthe left internal ostium 104 to the top of the uterine cavity 126. Theopposite maneuver takes for the right catheter 66 that allows the deviceto be deployed fully to the top of the uterus to direct lavage fluidaway from the internal ostia 104,106. Rotation of the wheel in counterclockwise fashion on the left side 26 b allows for this deployment.Placement and rotation 108,110 of these catheters are performed underultrasound guidance.

FIG. 54 is an anterior posterior view of the uterus showing analternative Version 2a, strategy for insertion and rotation of both thesupply lines 64 66 up the middle of the uterus to the top of the uterinecavity 126 with rotation of the control wheels 26 a, 26 b away from anddownward from the internal tubal ostia 104, 106. This allows for lavagefluid to be delivered away from the internal ostia 104,106 and directlyto the inner cervical funnel balloon 48 allowing for the embryos to berecovered with 100% efficiency and low risk of retrograde flow into theoviducts through the internal ostia 104,106 into the tubes 86.

FIG. 55 is an anterior posterior view of the uterus showing Version 2bright and left fluid supply lines with magnetized tips 68, 70 that allowlinkage of the catheters together at the top of the uterine cavity 126.This maneuver surrounds embryos within a closed mechanical perimeter.The magnetic tipped catheters are guided with the steering controls 26 a26 b. With ultrasound control, the magnetic tips are directed togetherand linked firmly at the top and middle of the uterine cavity 126 thussurrounding the embryos. Lavage fluid is then infused under high pulsepressure that breaks up the uterine fluid and mucous in the lower partof the uterine cavity 126 and delivers embryos to the internal funnelballoon 48 and suction line port at the bottom of the uterus.

FIG. 56 shows the effect of withdrawing the Version 2b catheter duringthe lavage by linking and pulling the steering controls outwardsimultaneously. The perimeter around the embryos shrinks with thismaneuver. Continued delivery of pulsatile fluid inside the shrinkingperimeters allows the embryos to be delivered with virtually 100%recovery to the internal suction port at the base of the balloon funnel.

FIG. 57 is an anterior posterior view of the Version 2b right and leftfluid supply lines 64, 66 with magnetic tips 68, 70 breaking contact atthis point as the fluid supply lines 68, 70 are withdrawn simultaneouslyfrom the uterine cavity. The magnetized tips break the perimeter afterembryos have already been delivered through the suction port to thesuction line.

FIG. 58 is an anterior portion of the Version 2b right and left fluidsupply line with magnetized tips 68 70 not making contact and beingwithdrawn separately from the uterine cavity 68 and 70.

FIG. 59a shows the separated ball and socket magnetized tips 68 70 atthe top of the fundus.

FIG. 59b shows the ball and socket 68, 70 magnetized tips in engagedposition.

FIG. 60a shows details of the ball and socket magnetic tips 68 70 withoblique views 68 and 70.

FIG. 60b is a cutaway 66 and 70.

FIG. 61a shows the anterior and posterior views of the deflated funnelballoon.

FIG. 61b shows a fully inflated balloon and showing the dual tips of theright and left fluid delivery catheters 64, 66.

FIG. 62a shows the Version 2 fully inflated funnel balloon from theoutside left.

FIG. 62b shows the fully inflated funnel balloon in cutaway.

FIGS. 63a-q show the Version 2a catheter placement and direction oflavage fluid flow. Lavage fluid emanating from the ports of the rightand left catheters 64, 66 direct embryos into the inflated balloonfunnel for egress into the intake ports of the uterine suction line 16and into the recovery trap 28. Version 2a, using double fluid supplylines, produced a flow of intrauterine fluid during lavage, as shown inFIGS. 63a -q.

In FIG. 63a the device with double supply lines 64, 66 is inserted intothe endocervical canal to a limit preset by the cervical stop 14. Theballoon collar 12 is shown uninflated 44. The embryos are shown in themiddle of the uterine cavity 88.

In FIG. 63b the balloon collar is deployed 46 under tension from thesupply line 16 and cervical collar stop 14. Upon inflation the balloonforms a watertight funnel at the endocervical canal. The two supply linecatheter tips, left 64 and right 66, are protected inside the ballooncollar at the very distal tip of the supply line 16.

In FIG. 63c the right supply line 66 is being deployed to the rightuterine wall snug tightly by the internal memory of the catheter tip.Proximal and distal steering of the supply line 66 is controlled byproximal and distal motion of the steering control right side 26 a thatmotion is directed through the resin slider block 118, which in turn islinked to the right operating slide.

In FIG. 63d the right supply line and its tip is directed up the uterinewall toward the internal ostia. It is steered away from the embryos 88to the ostium on the right 106. The embryos 88 are not disturbed in themiddle part of the uterine cavity.

In FIG. 63e the supply line catheter tip has been introduced to theinternal ostium 106 and 66. Its memory directs it along the uterinewall.

In FIG. 63f once the supply line has been imbedded into the ostium 106,the catheter is rotated 180 degrees by a clockwise torsion of thesteering control right 26 a.

FIG. 63g right shows 180 degrees torsion of the supply line and theports 72 and the flow direction of the supply line 66, its memoryreversed by the rotation.

FIG. 63h shows continued advancement of right fluid supply line 64 whereit contacts the uterine cavity 126 sidewalls and with continuedadvancement reaches the middle part of the upper uterine cavity 126 thencontacting at the very top of the cavity 126

In FIG. 63i the left supply line 64 is now advanced along the leftuterine wall.

In FIG. 63j the advancement continues unrestricted by the memory of theleft supply line 64 and continues it advancement to the left internalostium 104.

In FIG. 63k the left uterine supply line 64 has reached the internalostium 104 on the left and is partly inserted into the internal ostium104 but not advanced any further. The steering control left 36 b isrotated counterclockwise 180 degrees and the catheter 64 is thenredirected by internal memory to the middle part of the uterine fundus.

In FIG. 63l the advanced supply line meets its companion at the top ofthe uterine cavity 126 where they may touch.

In FIG. 63m pulsing flow has begun by prompting the programmablecontroller (not shown) linked by the uterine supply lines 64, 66. Fluidflow from the both the left and right supply lines 64 and 66 is directedto the center of the uterine cavity 126 where the embryos are located 88and the mechanical perimeter is formed around the embryos 88 and allfluid directed away from the internal ostia 106 and 104 into the ballooncollar 46 and in alternating sequence of pulse and suction.

In FIG. 63n embryos are directed into the suction line 16 through thefunnel collar 46 at the base of the funnel 46.

In FIG. 63o-q embryos are passing progressively into the port of thesuction line 16 at the base of the balloon collar funnel 46, clearedcompletely from the uterine cavity, and are delivered into the embryotrap 28 a. The fluid is taken the laboratory for evaluation of recoveredembryos.

FIG. 64a shows the Version 2b with magnetic tips 68, 70 placement,method of embryo entrapment and direction of fluid flow. Fluid emanatingfrom the ports of the right and left catheters direct embryos into theinflated balloon funnel for egress into the intake port of the uterinesuction line and into the recovery trap. The magnetic tip catheter is inmechanical perimeter to entrap embryos completely with withdrawal ofboth sides simultaneously allowing for virtually no escape of embryosinto the internal ostia. The pull of the catheters as they approach thefunnel allows the magnetic tips to break contact and then lead towithdrawal of both catheters.

FIGS. 64b-e depict intrauterine flow from dual supply lines directed tothe endocervical balloon guide collar 46. This system differs fromVersion #2b in that both tips have powerful magnets that allow them tojoin at the top of the fundus at full deployment.

In FIGS. 64b , this Version 2b system uses, for example, the samecatheter lengths as does the Version 2a system. In some implementations,there is no difference between systems other than the magnetic tips.

In FIG. 64c , the left supply line 66 and right supply line link at thetop of the fundus firmly attached by magnetic tips 68 and 70. Theembryos are surrounded by a mechanical and fluid barrier and cannotescape through the internal ostia 106 and 104 Pulsating fluid isdelivered to the central part of the uterine cavity where the embryo islocated 84 and alternating suction is delivered to the balloon collar 46and suction line 16 and the embryos are delivered into the suction.Because of mechanical perimeter and the flow of fluid, there should beno loss of fluid either to the internal ostium 104 and 106 or throughthe cervix.

In FIG. 64d the complimentary magnetic tips maintain a perimeter aroundthe embryos, which gently collapses contracting because the catheter isbeing withdrawn. The catheters at this stage cannot separate 64 and 66because they are held firmly together by a magnetic tip 68 and 70. Theembryos are entrapped into diminishing perimeter while they are beingdelivered into the suction line 16 at the base of the balloon collar 46.The perimeter is in its smallest dimension and the catheters 64 and 66are withdrawn and the magnetic tips 68 and 70 are being separated. Theflow of fluid is stopped at this point.

In FIG. 64e the right and left distal supply lines are now withdrawninto their ports at the base of the balloon collar at the distal thesuction line. The procedure is now ended and the instruments areremoved.

We have described a variety of implementations of the devices andtechniques that we have introduced above. A wide variety of otherimplementations, examples, and applications fall within the scope of ourconcepts.

For example, other approaches to recovering the embryos from the woman'suterus may be possible using other fluid-based and possiblynon-fluid-based techniques and combinations of two or more of them.Important goals in whatever techniques are used are to recoveressentially all of the embryos that are present in the uterus (whichimproves the efficiency of the process), to avoid delivering any fluidor other foreign material into the Fallopian tubes, to perform theprocedure safely and with the least discomfort to the woman, and toperform the procedure in the shortest time and with the least expertisenecessary.

Once the embryos are recovered, a wide variety of procedures, diagnoses,and treatments can be applied to them, not limited to genetic diagnosisor sex determination and associated treatment. The embryos could be usedfor and treated in accordance with any ethical purpose.

When lavage is used to recover the embryos, a wide variety of approachesand parameters can be applied. For example, any fluids or combinationsof two or more of them can be used, provided that they are safe andeffective and can successfully cause the embryos to be flushed from theuterus. Although we have referred to the fluid as entraining the embryosfor removal, other fluidic mechanisms to remove them may be safe andeffective, including flushing, spraying, pooling, or any combination ofthose and others.

We have referred to pulsating the lavage fluid during the procedure, andpulsating and aspiration to remove the fluid from the uterus, possiblyin synchronization with the delivery pulses. A wide variety of otherregimes may be effective, including no pulsing of the delivery fluid,and profiles of changing delivery pressure and suction that might not becharacterized as pulsing. We use the term pulsating broadly to includeall of such regimes, for example. Similarly there may or may not besynchronization of the delivery pressure and suction pressure.

We have suggested above that one aspect of achieving a high recoveryrate for the embryos is to seal the uterus during the procedure so thatessentially none of the lavage fluid leaks out of the woman (possiblywith embryos in the fluid). Other techniques that might not becharacterized as sealing may be possible to use to achieve a similarhigh recovery percentage of the fluid and embryos. When sealing is used,the sealing may be done at other locations than at the entry of thecervix into the uterus. In any case, it is considered useful to do thesealing in a manner that is relatively simple, easy to achieve, safe,effective, and can be effected from outside the woman's body by the sameperson who is performing the other steps of the procedure. Sealing canbe achieved in a variety of ways other than or in combination with aninflatable balloon, including other inflatable or non-inflatable devicesor mechanisms. In some examples, it is useful to arrange the sealingdevice so that it can be inserted in a non-inflated or non-deployedstate and then be inflated or deployed.

In many of the examples that we mentioned earlier, the lavage isachieved by multiple streams of fluid aimed toward the center of theuterus. A wide variety of approaches and combinations of them may bepossible. In general, a goal is to assure that all parts of the uterus,and especially the central region where the preimplantation embryos tendto be located, are washed by fresh lavage fluid so that every embryo isimpacted by the fluid. Then the fluid with the embryos present iscollected by any technique that can avoid the loss of embryos.

It is useful as part of the procedure to seat the lavage instrument at apredetermined insertion position relative to the woman's specificanatomy in order for the fluid to be effectively delivered andrecovered. We have described examples in which the distance between twoelements of the instrument is adjusted according to the distance betweenthe end of the cervix that opens into the vagina and the end of thecervix that opens into the uterus. This technique could be combined orreplaced by other techniques for seating the instrument in a positionand orientation that permit safe and effective lavage of essentially allof the embryos in the uterus. The seating of the device is useful toassure a good seal against the leakage of fluid, and also to assure thatthe fluid carrying elements of the device can be deployed easily andeffectively and in the best location for lavage.

We have described implementations in which the lavage delivery andrecovery elements of the instrument are manipulated and deployed byrotation and extension of those elements relative to a static support. Avariety of techniques can be used for deployment in combination with orin substitution for that described approach with the goals of relativelyquick and easy deployment, effective lavage, and comfort of the woman,among others.

The examples of lavage instruments that we have described include lavageelements and sealing elements that can be moved, inserted, deployed,manipulated, and later withdrawn relative to a fixed or static portionof the device. In some examples, the lavage and sealing elements ridewithin a tube that is part of the static device. In someimplementations, devices for carrying fluid both for delivery andrecovery, and elements that enable manipulation from the proximal end ofthe tool are located outside the woman during the procedure.

A wide variety of other or supplemental configurations of the tool arepossible alone or in combination. The configurations, materials,constructions, sizes, and interrelationships of the static and movableelements of the instrument can vary widely depending on the particularapproach chosen to achieve lavage. More than two catheters could beused. Each catheter could have more or fewer nozzles than in theexamples discussed earlier. The arrangement, sizes, shapes, anddirections of the nozzles can be varied. The manner in which thecatheters move and are manipulated relative to the fixed part of theinstrument can be varied. Any configuration that enables easy, quick,effective, safe, and comfortable lavage procedure could be considered.

The balloon, if used, could have a non-funnel shape. More than oneballoon could be used. The suction drain need not be located in thefunnel.

Other implementations are within the scope of the following claims.

For ease of reference, the following key identifies numerals on thefigures and related items associated with those numerals.

-   Operating Frame 8-   Steel Ball Tip—10-   Balloon Collar—12-   Cervical Stop—14-   Suction Line Distal—16-   Balloon Air Supply—18-   Fluid Supply Line—20-   Suction Recovery Line with One Supply Line Channel—22 a-   Suction Recovery Line with Two-Supply Line Channels—22 b-   Suction Recovery Channel—23-   Vacuum Line External Access Port—24-   Operating Slide—25-   Operating Slide Right—25 a-   Operating Slide Left—25 b-   Steering Control—26-   Right Steering Control—26 a-   Left Steering Control—26 b-   Embryo Recovery Trap—28 a-   Sealed Transport Vial 28 b-   Flat Petri Dish Large—28 c-   Flat petri dish Small—28 d-   Embryo Recovery Trap Perforated Stopper—29-   From Pulse Supply Pump—30-   To Pulse Suction Vacuum—32-   Insulated Transport Block—31-   Glass Stopper—33-   Fluid Supply Guide Channel—34-   Transport Media (e.g. Heapes Buffer)—35-   Fluid Supply Line—36-   Funnel—37-   Beveled High Flow Port—38-   Filter—39-   Beveled Low Flow Port—40-   Balloon Suction Port—42-   Collapsed Balloon—44-   Inflated Balloon—46-   Funnel Balloon under stretch from Cervical Stop—48-   Funnel Balloon under stretch from Cervical Stop Sectional View—50-   Supply Catheter Tips—52-   Fluid Supply Line Patient Left—64-   Fluid Supply Line Patient Right—66-   Magnetized Steel Cup—68-   Magnetized Steel Ball—70-   Top Endometrial Cavity—71-   Fluid Supply Port—72-   Cervical Stop Scale—74-   Catheter Platform Hand piece—76-   Magnetized Tips Disengaged—78-   Uterus—80-   Endometrial Lining—82-   Merger Block one Supply Line Channel—84 a-   Merger Block two Supply Line Channels—84 b-   Proximal Fallopian Tube—86-   Distal Fallopian Tube—87-   Embryos (Blastocysts)—88-   Peritubal Ovarian Interface—89-   Cervix—90-   Embryos Pronucleate (one cell) Stage—91-   Vagina—92-   Move Catheter up the uterine wall—94-   Right Middle Endometrial Cavity—95-   Fluid flow—96-   Left Middle Endometrial Cavity—97-   Move Catheter up the center of the uterus—98-   Hi flow fluid—100-   Low flow fluid—102-   Tubal Ostium Patient Left—104-   Tubal Ostium Patient Right—106-   Turn counterclockwise—108-   Turn clockwise—110-   Magnetized Tips Engaged—112-   Pull Catheters Downward—114-   Air Supply Syringe—116-   Slider Block Version #1—118-   Slider Block Version #2 Left-119 a-   Slider Block Version #2 Right-119 b-   Slider Block Lock—120-   Ovary—122-   Oocytes—124-   Uterine Cavity—126-   Expanded Uterine Cavity 127-   Sperm—128-   Insemination Catheter—130-   Blastocyst that have been selected or treated—132-   Zona Pellucida—133-   Trophectoderm Cells—134-   Inner Cell Mass—135-   Holding Pipette—136-   Suction Biopsy Pipette—138-   x Chromosome Signal—140-   18 Chromosome Signal—142-   13 Chromosome Signal—144-   21 Chromosome Signal—146-   Molecular Diagnosis of Trisomy 21 In Situ Hybridization—148-   Embryo Transfer Catheter—150-   Superovulation—152-   Fundus—153-   Artificial Insemination—154-   Internal os—155-   In Vivo Fertilization—156-   Endocervical Canal—157-   Uterine Lavage—158-   Embryo Blastocyst Recovery—159-   Embryo Biopsy—160-   Uterine Fluid—161-   Preimplantation (Molecular) Diagnosis—162-   Preimiplantation Genetic Therapy Intervention—164-   Blastocyst Replacement—166-   Cryopreservation—165-   Birth—168-   External os—170-   Corporate Regional Coordinating Center—172-   Core Laboratory—174-   Service Area with 150-Mile Radius—176-   Subscriber Clinic—178-   Secure Area Subscriber Clinic—179-   Secure Computer Terminal—181-   Woman Patient and Male Partner—183-   Electronic Identification Chip—189-   Transport Vial Carrying Case—190-   Secure Space Core Embryology Lab—192-   Secure Computer Terminal—194-   Frozen Blastocyst Container—196-   Hard Stand—198-   Hard Stand Attachment Point—199-   External Controller—205-   218—GnRH agonists-   220—GnRH antagonist-   222—LH-   223—hCG-   224—FSH-   226—Progesterone antagonist-   228—Progesterone-   230—Estradiol-   231—Pinch Valve-   232—Controller Pump-   233—Vacuum Pump

What is claimed is:
 1. A method of inducing corpus luteum apoptosisleading to desynchronization of the endometrium in a female patient,comprising recovering blastocysts and administering a GnRH antagonist tothe patient such that corpus luteum apoptosis is induced wherein theGnRH antagonist is administered daily for up to ten days or until theonset of menses following blastocyst recovery to induce said corpusluteum apoptosis.
 2. The method of claim 1, further includingadministering the GnRH antagonist on the day in which the blastocystsare recovered.
 3. The method of claim 1, wherein the GnRH antagonist isadministered at a dosage amount of about 0.10 to 400.0 mg.
 4. The methodof claim 1, wherein the GnRH antagonist is administered at a dosageamount of about 0.5 to 10.0 mg.
 5. The method of claim 1, wherein theGnRH antagonist is administered at a dosage amount of about 0.5 to 5.0mg.
 6. The method of claim 1, wherein the GnRH antagonist isadministered at a dosage amount of about 0.25 to 3.0 mg.
 7. The methodof claim 1, wherein the GnRH antagonist is administered at a dosageamount of about 3.0 mg.
 8. The method of claim 1, further comprisingadministering a progesterone receptor antagonist to the patient.
 9. Themethod of claim 8, wherein the progesterone receptor antagonistcomprises a dosage of about 600 mg.
 10. The method of claim 8, whereinthe progesterone receptor antagonist comprises a dosage of between 100to 200 mg.
 11. The method of claim 8, wherein the progesterone receptorantagonist comprises Org31710 at a dosage of between 10 to 75 mg.
 12. Amethod for inducing corpus luteum apoptosis leading to desynchronizationof the endometrium following recovery of blastocysts from the uterus ofa patient, the method comprising administering a GnRH antagonist in apharmaceutically acceptable carrier at a dosage amount of about 0.5 to400 mg to the patient after superovulation daily for up to ten days oruntil the onset of menses following blastocyst recovery to induce corpusluteum apoptosis.
 13. A method of inducing corpus luteum apoptosisleading to desynchronization of the endometrium in a female patient,comprising recovering blastocysts and administering a GnRH antagonist tothe patient on the day in which the blastocysts are recovered such thatcorpus luteum apoptosis is induced.